Aventura at Pembrooke: Scalding Water Immediate Jeopardy - PA
That was the morning of December 26, 2025. The nursing home had been in the middle of a water crisis for days. A plumber had come and gone without fixing anything. The hot water was supposed to be shut off throughout the building while repairs continued. Residents were getting bed baths with disposable washcloths instead of showers. And on the morning an inspector walked into that ground-floor bathroom and felt the scalding water burn their skin, the administrator and the director of nursing were both somewhere else.
The facility is on West Chester Pike, a 19380-zip-code address in a Pennsylvania suburb. Federal inspectors had been there before the holiday. They came back on Christmas Eve, then again on December 26, then December 27. What they found across those four days, documented in a complaint inspection completed December 28, 2025, was a facility that had lost control of its water system, lost track of what temperature that water was running at, and lost contact with its own leadership at the moments it needed them most. Inspectors cited the conditions as an immediate jeopardy, the most serious classification available under federal nursing home oversight, meaning the situation posed an immediate threat to resident health or safety. Many residents were affected.
On Christmas Eve, at 11:30 in the morning, the nursing home administrator sat down with inspectors and explained that the plumber had not finished the repairs. A second plumber was supposed to arrive by 1:00 p.m. The hot water remained off. Staff were still using the disposable washcloths. There were no temperature logs, no monitoring records, nothing on paper, because, the administrator explained, the water was off and there was nothing to measure.
The facility had, at some point before that conversation, put together a corrective action plan. It was detailed on paper. Daily random water temperature checks in resident rooms, shower rooms, and common areas for seven days, then weekly checks for four weeks, then monthly checks ongoing. A maximum allowable temperature of 110 degrees Fahrenheit. Thermometers, not hand-testing. Documentation on a Water Temperature Monitoring Log. Staff education on acceptable ranges, on how to use a thermometer, on why hand-testing was prohibited because of the risk of injury and inaccuracy, on what to do if a temperature came back out of range.
None of it was happening yet on Christmas Eve. The water was still off, the plan was still on paper, and a second plumber was on the way.
Two days later, the inspector walked into the ground-floor bathroom, the same bathroom where the original hot water problem had been identified, and the water was steaming. The surveyor's hand turned red.
A licensed nursing employee, identified in the inspection report as Employee E6, was nearby. She said the administrator and the director of nursing were not in the building. She was asked to find the maintenance director. The inspector could not locate him either.
The shower rooms on the first, second, and third floors ran cold.
Three nursing employees, E7, E8, and E9, were interviewed at 9:45 that morning. Two of them said they were still giving residents bed baths with disposable washcloths, the same method that had been in place since the hot water went off. The third, Employee E9, said something different: they were using hot water in basins.
That was a problem. If the hot water was running somewhere in the building, and staff were drawing it into basins to bathe residents, and nobody was measuring its temperature, and the facility's own corrective plan prohibited hand-testing because of the risk of injury, then residents were potentially being bathed in water nobody had checked.
The administrator, reached by phone at around 10:00 a.m. that morning, said a plumber had come the previous night and still could not fix it. The plumber might have turned the hot water on in the lobby bathroom and forgotten to turn it back off. That appeared to be the explanation for the steaming faucet and the red mark on the surveyor's hand. There was no monitoring of water temperatures, the administrator confirmed, because the facility believed the hot water was off throughout the building.
They had been wrong.
The next morning, December 27, inspectors returned. The administrator was not there. The director of nursing was not there. The maintenance director was not there. Two licensed nursing employees, E10 and E11, were interviewed within five minutes of each other, at 8:30 and 8:35 a.m.
Employee E10 said: "They didn't tell me anything about the showers, I'm agency. Talk to the aides, they should know."
Employee E11 said: "I don't know what you're talking about, I'm agency. They called me here last minute."
Both were agency nurses, brought in from outside the facility, working Christmas weekend at a nursing home in the middle of a declared immediate jeopardy, with no knowledge of the water crisis, no briefing on the corrective plan, no information about what residents were or weren't supposed to be receiving in terms of bathing.
The inspectors asked for the temperature verification logs. They asked for documentation that staff had been educated on the corrective plan, the one that specified thermometers at every nursing station, in every shower room, at the receptionist desk.
The director of nursing, reached by phone at 9:30 a.m., confirmed he was not at the facility. Neither was the administrator. Neither was the maintenance director. When the inspectors asked about the logs and the education records, the director of nursing said the administrator had the information but was unavailable until after 6:00 p.m.
It was 9:30 in the morning on December 27.
The facility's corrective plan had required staff education to be provided before the start of each shift. The two agency nurses working that morning had received none. The temperature logs that were supposed to document daily checks of resident rooms, shower rooms, and common areas did not exist, at least not in any form the director of nursing could produce. The administrator, who apparently had whatever records did exist, would not be reachable for more than eight hours.
Inspectors came back on December 28. By that point, observations of resident rooms and shower rooms, review of the facility's temperature logs, review of staff education documentation, and interviews with 15 nursing and ancillary staff confirmed that the corrective action plan was finally being implemented. Immediate jeopardy was lifted at 11:50 a.m.
The inspection cited violations under multiple Pennsylvania Department of Health codes covering licensee responsibility, management, resident care policies, and nursing services.
What the record shows, across four days from Christmas Eve to December 28, is a facility that knew it had a water problem, wrote a plan to address it, and then did not execute that plan while its top three leaders were absent from the building on back-to-back days. Agency nurses arrived for shifts with no information. A plumber came and left without fixing anything, then may have left scalding water running in a bathroom and said nothing. A surveyor pressed their hand under a faucet and pulled it back marked red.
The residents who needed showers during those days got washcloths instead, or basin baths drawn from water no one had measured, in a building where the person who knew where the logs were kept was not available until evening.
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 immediate jeopardy violations during a health inspection on December 28, 2025.
That was the morning of December 26, 2025.
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.