Aventura at Pembrooke: Wound Care Falsification - PA
The inspection at Aventura at Pembrooke, a nursing facility at 1130 West Chester Pike, took place November 3, 2025, and was triggered by a complaint. What inspectors found that morning was not a paperwork error. It was a nurse who had charted care that had not happened.
The resident, identified in the report only as Resident R2, had a Stage 4 pressure injury to the sacrum, the bone at the base of the spine. Stage 4 is the most severe classification, meaning the wound had eaten through the full thickness of skin and tissue. R2's wound measured 1.2 by 0.8 by 0.2 centimeters and was producing moderate clear drainage. A physician had ordered daily treatment: rinse with normal saline, apply a nickel-thick layer of Santyl ointment to break down dead tissue, and cover with a dry dressing.
At 11:35 in the morning on November 3, inspectors observed the wound directly, with two licensed nurses present. The brief came open. There was stool. There was no dressing.
The nurse assigned to Resident R2, identified as Employee E9, was interviewed five minutes later. She confirmed she had documented the wound treatments as completed, entering the record somewhere between 9:30 and 10:00 that morning while she was working on the resident's behavior documents. She then confirmed the treatments had not actually been performed.
She had charted care she had not given.
The treatment record also showed the wound had gone untreated the day before. November 2 had no wound care. The Director of Nursing, interviewed that afternoon at 3:00 p.m., could not explain why.
What makes this harder to dismiss as an isolated lapse is the citation history. The same deficiency, wound care and nursing services, had been cited at Aventura at Pembrooke just ten weeks earlier, on August 25, 2025. The November inspection report flags both violations as previously cited, listing the same Pennsylvania regulatory codes for clinical records and nursing services. A facility gets cited once and is expected to fix the problem. Aventura at Pembrooke was cited again for the same category of failure before the year was out.
A Stage 4 wound at the sacrum is particularly vulnerable to contamination. The sacrum sits directly adjacent to the area where incontinence occurs. A wound left undressed in that location, without the barrier a dressing provides, is exposed to exactly the kind of contamination inspectors observed that morning. Santyl, the ointment ordered for R2, works by chemically dissolving necrotic tissue so the wound can heal. Skipping the treatment does not simply delay healing by one day. Dead tissue left in place creates conditions where infection can take hold and spread.
The inspection covered three residents' wound care. The failures were found in one of the three reviewed.
Aventura at Pembrooke has not publicly responded to the findings. The plan of correction, if one has been submitted, was not included in the materials released.
Resident R2's wound was a centimeter wide and had a physician's order, a treatment record, and a nurse assigned to carry out the care every day. On November 2, nobody did it. On November 3, the nurse wrote down that she had, then told inspectors she had not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Pembrooke from 2025-11-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on November 3, 2025.
The inspection at Aventura at Pembrooke, a nursing facility at 1130 West Chester Pike, took place November 3, 2025, and was triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.