Aventura At Pembrooke
AVENTURA AT PEMBROOKE in WEST CHESTER, PA — inspection on December 28, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
medication ordered by the physician for one of three residents reviewed (Resident CL1).
Findings
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].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 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395166 12/28/2025
Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380
Observation of the shower rooms on the first, second, third floor revealed the water was cold to touch.
Interview with three Nursing Employees E7, E8, and E9 on December 26, 2025, at 9:45 a.m. revealed two of the three said they were giving the residents bed baths with disposable washcloths but Nursing Employee E9 stated they were using hot water in basins to give the residents bed baths.
Telephone Interview with the NHA on December 26, 2025, at approximately 10:00 a.m. revealed a plumber had come to the facility the previous night and was still unable to correct the water problem and might have turned the hot water on the lobby bathroom and forgot to turn it back off.
There was no monitoring of water temperatures because they thought the hot water was turned off throughout the facility.
Interview conducted with Licensed Nursing Employees E10 on December 27, 2025, at 8:30 a.m. revealed, they didn't tell me anything about the showers, I'm agency.
Talk to the aides, they should know.
Interview with Licensed Nursing Employee E11 on December 27, 2025, at 8:35 a.m. stated I don't know what you're talking about, I'm agency.
They called me here last minute.
The NHA, DON, and Maintenance director were not observed to be present in the building.
Telephone interview conducted with the DON on December 27, 2025, at 9:30 a.m. confirmed he was not at the facility nor was the NHA or Maintenance Director.
When asked for temperature verification via logs for temperature monitoring of the water or education provided to the staff, the DON revealed the NHA has the information but was unavailable until after 6:00 p.m.
Observations conducted on December 28, 2025, of resident rooms and shower rooms as well as review of facility temperature logs, review of facility staff education documentation, and interviews conducted with 15 nursing and ancillary staff confirmed the above stated action plan was implemented and immediate jeopardy was lifted on 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
395166 12/28/2025
Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380
Observations of Residents 1 and 2 on December 23, 2025 at 9:45 a.m. revealed both residents had a
(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
395166 12/28/2025
Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380
appearance of the urine and checks for blood cells, proteins, and other substances in it) ordered by
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,
- 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
395166 12/28/2025
Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380
effectively manage the facility to ensure the safety of residents due to hot water temperatures.
This
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
395166 12/28/2025
Aventura at Pembrooke 1130 West Chester Pike West Chester, PA 19380
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
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.