Aventura at Pembrooke: Lab Failure Delayed UTI Care - PA
That is the sequence inspectors documented at Aventura at Pembrooke following a complaint investigation completed December 28, 2025.
A physician ordered a urinalysis with culture and sensitivity for a resident, identified in inspection records as Resident CL1, on October 13, 2025. The order was tied to acute kidney failure. The sample was collected that same day. The lab received it on October 14 and rejected it. The reason: unlabeled specimen.
Nobody followed up. No new sample was collected. The physicians were not notified that the test had failed until October 20, seven days later. A new order went in that day.
The second sample, collected October 21, came back positive for Klebsiella pneumoniae ESBL, a drug-resistant bacterial strain, with a colony count above 100,000. That number indicates an active infection. The physician prescribed Augmentin, 875 milligrams twice daily for seven days, for a urinary tract infection.
The Director of Nursing confirmed both failures during an interview on December 23, 2025: the lab rejected the first sample because of improper labeling, and no follow-up was done until October 20.
The same two state code citations attached to this inspection, covering clinical records and nursing services, had been cited at this facility twice before, in August and November of 2025.
Resident CL1 spent a week with an untreated infection, the severity of which only became visible once someone finally collected a second sample.
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.
That is the sequence inspectors documented at Aventura at Pembrooke following a complaint investigation completed December 28, 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.