Aventura at Pembrooke: Lab Test Delays Worsen UTI - PA
The physician ordered a urinalysis on October 13 for the resident, who had acute kidney failure. Staff collected the urine sample that same day, according to treatment records reviewed by state inspectors at Aventura at Pembrooke.
The laboratory received the specimen on October 14 but couldn't process it. The report stated simply: "Specimen received, unlabeled."
Nobody followed up. The resident's urine was never recollected for testing, and the physician wasn't notified about the missed test until October 20 — a full week later.
When staff finally collected a new sample, the results revealed a serious infection. The October 21 laboratory report showed the resident tested positive for Klebsiella Pneumoniae ESBL, with a colony count above 100,000 indicating an active urinary tract infection.
The physician immediately prescribed Augmentin, an antibiotic, for seven days.
During a December 23 interview with inspectors, the Director of Nursing confirmed that the original urine sample wasn't tested due to improper labeling. She also acknowledged that staff didn't follow up on the missed test until October 20.
The facility's own policy requires staff to "process the test requisitions and arrange for tests" when physicians order laboratory work based on residents' diagnostic needs.
This wasn't the first time Aventura at Pembrooke faced scrutiny over clinical records and nursing services. State regulators previously cited the facility for similar violations on August 25 and November 3.
The week-long delay meant the resident lived with an untreated infection that required immediate antibiotic intervention once properly diagnosed.
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 20, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on December 28, 2025.
The physician ordered a urinalysis on October 13 for the resident, who had acute kidney failure.
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.