Aventura at Pembrooke: Infection Control Failures - PA
The resident, identified in inspection records as Resident 2, had a tracheostomy, a procedure that creates a direct opening into the windpipe through the neck, and was receiving tube feeding, which delivers liquid nutrition and medication through a soft tube when a person cannot eat or swallow safely. Both conditions place a resident at heightened vulnerability to infection. Neither a gown, gloves, nor a mask was present in the room. No sign had been posted on the door.
The inspection, conducted on December 23, 2025, found the same signage failure across four additional rooms: 102, 104, 108, and 115.
Those four rooms were not entirely without supplies. Inspectors observed a storage system hanging from each door that held gowns, gloves, and masks. The equipment was there. The posted notice was not.
The distinction matters. Under the facility's own infection prevention and control policy, effective February 24, 2025, staff are required to use enhanced barrier precautions for any resident with a wound or an indwelling medical device, regardless of whether that resident is known to carry a drug-resistant organism. The policy also requires a notice posted outside the room. The precautions apply not because infection has been confirmed, but because the resident's condition creates the conditions for one.
For Resident 2, the gap was complete. No sign. No supplies.
Inspectors noted their findings to the Nursing Home Administrator and the Director of Nursing at 2:45 p.m. on the same day observations were made.
Enhanced barrier precautions exist precisely because drug-resistant infections do not announce themselves. A resident can carry or develop a dangerous organism without any outward sign. The posted notice outside a room is not a formality. It tells every person who walks through the door, whether a nurse, an aide, a dietary worker, or a visitor, that protective equipment is required before contact. Without it, the decision to gear up or not gets left to individual judgment, or habit, or whether anyone noticed the supplies hanging on the door.
For a resident breathing through a surgically created hole in their neck and receiving nutrition through a tube, the margin for error is narrow.
The facility's own policy did not require a new regulation to trigger these protections. It required wounds or indwelling devices. Resident 2 had both. Four other residents had conditions that placed them in the same category. The policy had been in place for ten months by the time inspectors walked through the door.
The inspection was classified as a complaint survey. The level of harm was recorded as minimal harm or potential for actual harm, and the findings affected few residents. Those designations reflect regulatory categories. They do not change what an inspector found at 9:50 in the morning: a medically fragile resident in a room where the basic architecture of infection prevention had not been assembled.
The supplies for four other rooms were present but unmarked. For Resident 2, nothing was in place at all.
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: 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: August 17, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on December 28, 2025.
Both conditions place a resident at heightened vulnerability to infection.
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.