Aventura at Pembrooke
1130 West Chester Pike · West Chester, PA · 19380 · 6106923636
180 certified beds For profit - Corporation Chain: Aventura Health Group
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $85,255 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$85,255 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.65 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.49 | 0.55–0.75 |
| Weekend hours / resident-day | 3.28 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $85,255 |
Inspection citations (31 in the current record)
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Potential for harm · D March 26, 2026 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected April 22, 2026 · Quality of Life and Care
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Immediate jeopardy · L December 28, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 21, 2026 · Quality of Life and Care
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Potential for harm · D December 28, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 21, 2026 · Quality of Life and Care
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Potential for harm · D December 28, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 21, 2026 · Quality of Life and Care
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Potential for harm · D December 28, 2025 · found via complaint
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected January 21, 2026 · Administration
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Potential for harm · F December 28, 2025 · found via complaint
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected January 21, 2026 · Administration
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Potential for harm · D December 28, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected January 21, 2026 · Infection Control
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Actual harm · G November 3, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 18, 2025 · Quality of Life and Care
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Actual harm · G November 3, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 18, 2025 · Quality of Life and Care
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Potential for harm · D November 3, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected November 18, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 3, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 18, 2025 · Quality of Life and Care
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Potential for harm · D August 22, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 22, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · D August 22, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · D August 22, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · E August 22, 2025
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · D August 22, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected September 29, 2025 · Pharmacy Service
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Potential for harm · D August 22, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected September 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 25, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected August 16, 2024 · Resident Rights
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Potential for harm · D July 25, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 16, 2024 · Quality of Life and Care
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Potential for harm · D July 25, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected August 16, 2024 · Pharmacy Service
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Potential for harm · D July 25, 2024
Provide or get specialized rehabilitative services as required for a resident.
Corrected August 16, 2024 · Quality of Life and Care
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Potential for harm · D June 27, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 12, 2024 · Resident Assessment and Care Planning
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Potential for harm · D March 21, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 5, 2024 · Quality of Life and Care
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Potential for harm · D September 8, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected November 5, 2023 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 28, 2025 | Fine | $85,255 |
| August 3, 2023 | Payment Denial | 2 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 395166 · certified since December 1, 1976. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.