Aventura at Pembrooke: Lab Test Delay Worsened UTI - 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 on October 13. The test was processed that day. The lab received the specimen on October 14 and flagged it immediately: unlabeled.
No one followed up. No retest was ordered. The physicians were not told the sample had been rejected until October 20, seven days later.
When staff finally collected a new sample and sent it to the lab on October 21, the results came back positive for Klebsiella pneumoniae ESBL, a drug-resistant bacterial strain, with a colony count above 100,000, indicating an active infection. The physician prescribed Augmentin, an antibiotic, twice daily for seven days.
The Director of Nursing confirmed both failures during an interview with inspectors on December 23. The DON acknowledged that the urine was not tested due to improper labeling and that no follow-up occurred until October 20.
The same two state citations issued in this inspection, covering clinical records and nursing services, had already been cited at Aventura at Pembrooke twice before, in August and November of 2025.
CL1 spent at least a week with an undiagnosed, active urinary tract infection caused by a strain of bacteria that resists many standard antibiotics, while a rejected lab slip sat unaddressed in the records.
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 21, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on December 28, 2025.
The test was processed that day.
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.