Aventura At Pembrooke
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review, and staff interview, it was determined that the facility failed to follow the medication ordered by the physician for one of three residents reviewed (Resident CL1). Findings include:A review of Resident CL1's diagnosis list includes Anemia (low red blood cell count) and chronic kidney disease (progressive condition where kidneys gradually lose their ability to filter waste and fluids from the blood).
The resident was admitted to the facility on [DATE REDACTED].Clinical records review revealed Resident CL1 was sent to the hospital for a blood transfusion on October 14,2025, and October 16, 2025, for a low Hemoglobin level (an iron-rich protein that carries oxygen from the lungs to the body's tissue and organs).A review of
the Physician's order, dated November 24, 2025, revealed an order for Aranesp (A medication used to treat anemia) 200 mcg/ml, inject 200 mcg intramuscularly (injection of a substance into a muscle) one time a day every Thursday.A review of Resident CL1's November and December 2025 Medication Administration
Record (MAR) revealed that the Aranesp was not administered to the resident on the following dates: November 27, 2025, December 4, 2025, and December 11, 2025.Nursing progress notes dated November 27, 2025, at 11:34 a.m., revealed Aranesp medication awaiting from pharmacy.Nursing progress notes dated December 4, 2025, at 11:24 a.m., Aranesp medication Awaiting from pharmacy, pharmacy called needs to be approved due to high cost, DON (Director of Nursing) was made aware.Nursing progress notes dated December 11, 2025, at 11:24 a.m., revealed Aranesp medication awaiting from pharmacy.An
interview was conducted with the DON on December 24, 2025, at 1:00 p.m. The DON reported that they were notified of the medication needing approval due to its cost. The DON reported giving approval via phone to the pharmacy on December 5, 2025, for the medication to be sent, but was unable to provide the name of the person they spoke to and was unable to provide documented evidence that the approval was made. The DON also confirmed that a follow-up was not made on December 11, 2025, when the medication was not sent by the pharmacy.Clinical records review failed to reveal that the physician was notified of the missed Aranesp dosage. The resident was discharged home on December 17, 2025.The facility failed to ensure physician's medication order to treat Resident CL1's Anemia was followed.28 Pa.
Code 211.5(f) Clinical RecordsPreviously cited 8/25/25, 11/3/202528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25, 11/3/25
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Pembrooke
1130 West Chester Pike West Chester, PA 19380
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety
December 28, 2025, at 11:50 a.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(2) Nursing services
Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Pembrooke
1130 West Chester Pike West Chester, PA 19380
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0695
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or potential for actual harm
Based on observations and staff interview it was determined the facility failed to label and date oxygen and suction tubing for two of two residents reviewed (Resident 1 and 2). Findings Include: Observations of Residents 1 and 2 on December 23, 2025 at 9:45 a.m. revealed both residents had a tracheostomy (a surgical procedure creating an opening (stoma) in the neck into the windpipe (trachea) to provide a direct airway for breathing, often using a tube, used for blockages, long-term ventilation, or secretion clearance) with a trach collar (a soft strap that secures a tracheostomy tube in place around the neck, preventing it from moving or dislodging, while also providing a way to deliver humidified oxygen or manage airflow directly to the airway opening) in place. Further observations revealed that both residents had suctioning set up at their bedside. Observations of the tubing for the oxygen and the suctioning and for the disposable canister for the suctioning revealed there was no date last indicating when it should have been changed.
Interview with the DON on December 23, 2025 at 10:30 a.m. revealed that the tubing should be dated with
the date it was last changed. 28 Pa code: 211.12(d)(1)(3)(5) Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Pembrooke
1130 West Chester Pike West Chester, PA 19380
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0770
F 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm or potential for actual harm
Based on review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure laboratory tests for Urinalysis (A set of tests that looks at the appearance of the urine and checks for blood cells, proteins, and other substances in it) ordered by the physician were timely followed (Resident CL1). Findings include:A review of the facility's policy titled Lab and Diagnostic Test Results-Clinical Protocol, undated, revealed that the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process the test requisitions and arrange for tests.A review of Resident CL1's Physician order dated October 13, 2025, revealed an order for Urinalysis, culture, and sensitivity one time only for frequency, irritation related to acute kidney failure.A review of the October 2025 Treatment Administration Record (TAR) revealed that the order for the urinalysis was done on October 13, 2025.A review of the laboratory report dated October 14, 2025, revealed Specimen received, unlabeled.Clinical records review failed to reveal that the urinalysis test was completed. The record revealed that no follow-up was done, and the resident's urine was not collected for re-testing since the initial urine was not tested due to improper labeling. The records also revealed that the physicians were not notified of the missed urine test until October 20, 2025. A new order to collect urine for urinalysis with culture and sensitivity was made on October 20, 2025.A review of the laboratory report dated October 21, 2025, revealed Resident CL1's urine was positive for an organism Klebsiella Pneumoniae ESBL, with a colony count of above 100,000 (indicating an active infection).The physician ordered Augmentin (antibiotic) 875 mg 1 tablet twice daily for seven days for Urinary tract infection (UTI).An
interview with the Director of Nursing was conducted on December 23, 2025. The DON confirmed that Resident CL1's urine was not tested by the laboratory due to improper labeling. The DON also confirmed that follow-up with the urine test was not done until October 20, 2025.The facility failed to ensure Resident CL1's urine test order was timely followed, which resulted to delay in treatment on the resident's urinary tract infection.28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/25, 11/3/202528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25, 11/3/25
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Pembrooke
1130 West Chester Pike West Chester, PA 19380
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0835
F 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm or potential for actual harm
Based on the review of job descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of residents due to hot water temperatures. This failure resulted in an Immediate Jeopardy situation.Findings Include: Review of the job description for the Nursing Home Administrator (NHA) states position purpose: Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Further review of the NHA position description revealed the Essential Function: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Review of the job description for the Director of Nursing (DON) states Position Purpose: Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. The findings in this report identified the facility failed to maintain the safety of the residents from hot water temperatures by ensuring that there was
a system in place to monitor the water temperatures and that staff were ensuring the water was a safe temperature prior to providing care to the residents. Refer to F-F689 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management
Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at Pembrooke
1130 West Chester Pike West Chester, PA 19380
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on facility policy review, observations and staff interviews it was determined the facility failed to provide PPE and signage for residents who require enhanced barrier precautions for four resident rooms and one resident (115, 108, 104, 102, and Resident 2)Findings Include: Review of facility policy titled Infection Prevention and Control, effective February 24, 2025, revealed Use EPB (enhance barrier precautions) for residents with wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism).post notice outside the resident room when on EBP. Observations of rooms 102, 104, 108, and 115 on December 23, 2025, at 9:45 a.m. revealed hanging from each door was a storage system with PPE (Personal Protective Equipment) Sucha as gowns, gloves and mask. Further observations revealed there were no signs on the door to post notice of the need for the PPE. Observation of Resident 2 on December 23, 2025 at 9:50 a.m. revealed the resident had a Tracheostomy (a surgical procedure that creates a new airway by making a hole (stoma) in
the neck directly into the windpipe (trachea) to help with breathing) and tube feeding (provides liquid food, fluids, and medicine directly into the GI tract via a soft tube when someone can't eat or swallow safely).
Further observations revealed there was no PPE in the room and there was no sign for EBP. These findings were relayed to the Nursing Home Administrator and the Director of Nursing on December 23, 2025, at 2:45 p.m. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
AVENTURA AT PEMBROOKE in WEST CHESTER, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WEST CHESTER, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVENTURA AT PEMBROOKE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.