Aventura at Pembrooke: Anemia Drug Delays - PA
The resident at Aventura at Pembrooke required blood transfusions on October 14 and October 16 for dangerously low hemoglobin levels. A month later, their doctor ordered weekly Aranesp injections to treat the anemia.
The facility failed to give the medication on three consecutive Thursdays in November and December 2025.
On November 27, nursing notes stated "Aranesp medication awaiting from pharmacy." The same excuse appeared December 4, with an added detail: "pharmacy called needs to be approved due to high cost, DON was made aware."
By December 11, staff wrote identical notes about waiting for the pharmacy.
The Director of Nursing told inspectors she approved the expensive medication by phone on December 5, but couldn't name who she spoke with or provide documentation of the approval. She admitted making no follow-up calls when the December 11 dose never arrived.
Nobody notified the resident's physician about the missed treatments.
The resident went home December 17 without receiving any of the prescribed anemia medication. They had chronic kidney disease, which progressively destroys the organs' ability to filter waste from blood, making the anemia treatment critical.
Inspectors found the facility violated state regulations requiring proper medication administration and clinical record keeping. Aventura at Pembrooke was previously cited for similar nursing service deficiencies in August and November 2025.
The inspection report lists the violation as causing "minimal harm or potential for actual harm" to residents.
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.
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 12, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on December 28, 2025.
The resident at Aventura at Pembrooke required blood transfusions on October 14 and October 16 for dangerously low hemoglobin levels.
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.
Frequently Asked Questions
- What happened at AVENTURA AT PEMBROOKE?
- The resident at Aventura at Pembrooke required blood transfusions on October 14 and October 16 for dangerously low hemoglobin levels.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in WEST CHESTER, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from AVENTURA AT PEMBROOKE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395166.
- Has this facility had violations before?
- To check AVENTURA AT PEMBROOKE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.