Aventura at Pembrooke: Lab Failure Delayed UTI Care - PA
The resident, identified in inspection records only as CL1, was dealing with acute kidney failure in October 2025 when a physician at Aventura at Pembrooke ordered a urinalysis with culture and sensitivity testing. Staff collected the sample on October 13. The lab received it the next day and returned a single notation: specimen unlabeled.
No one recollected the urine. No one told the physician.
The Director of Nursing confirmed both facts during an interview with inspectors on December 23, 2025. The DON acknowledged the lab rejected the sample due to improper labeling and that no follow-up was done until October 20, nearly a week after the lab flagged the problem.
When staff finally drew a new sample that day and sent it out, the results came back the following morning. The lab found Klebsiella pneumoniae ESBL, a drug-resistant bacterial strain, in the resident's urine at a colony count above 100,000, the threshold indicating an active infection. The physician prescribed Augmentin, 875 milligrams twice daily for seven days, to treat the UTI.
The same two violations cited in this inspection, related to clinical records and nursing services, had already been cited at Aventura at Pembrooke twice before: August 25, 2025, and November 3, 2025. The December inspection marked the third time in four months inspectors found the facility falling short on the same standards.
CMS rated the harm to Resident CL1 as minimal or potential for actual harm. What the rating doesn't capture is the week that passed while a resident in kidney failure carried an undetected, drug-resistant infection, and the only reason anyone found out was that a new order was finally written seven days after the first test never happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Pembrooke from 2025-12-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on December 28, 2025.
Staff collected the sample on October 13.
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.