AVENTURA AT PEMBROOKE
Open-data reference.
AVENTURA AT PEMBROOKE is a for profit - corporation facility in WEST CHESTER, PA with 180 certified beds and a 1-star overall CMS rating. The facility has 34 deficiency records on file.
1130 WEST CHESTER PIKE, WEST CHESTER, PA 19380
Phone: 6106923636
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 395166
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 180
- Residents
- 135
- In Hospital
- No
- County
- Chester
- Last Inspection
- Aug 22, 2025
Staffing Data
- RN Hours
- 0.40 (nat'l avg: 0.68)
- LPN Hours
- 1.05
- CNA Hours
- 1.98
- Total Nursing Hours
- 3.42 (nat'l avg: 3.89)
- PT Hours
- 0.03
What the CMS Record Reveals About AVENTURA AT PEMBROOKE
AVENTURA AT PEMBROOKE operates 180 certified beds in WEST CHESTER, PA with approximately 135 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 34 deficiency records from recent surveys, of which 5 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.42 total nursing hours per resident day (national average 3.89), with RN coverage at 0.40 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, AVENTURA AT PEMBROOKE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (34 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 18, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 29, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Sep 29, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 29, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 29, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 29, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 29, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 29, 2025
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 16, 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.
Category: Pharmacy Service Deficiencies
Corrected: Aug 16, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 16, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Aug 16, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 12, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 5, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Nov 5, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 5, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 5, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Nov 5, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 5, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 5, 2023
Honor the resident's right to manage his or her financial affairs.
Category: Resident Rights Deficiencies
Corrected: Aug 28, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Mar 29, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 29, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 29, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Mar 29, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 6.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.7% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.4% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.6% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.5% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 90.5% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 47.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 6.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 14.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.5% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 57.8% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 7.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 15.4% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 20.6% | Yes |
Penalty History
| Date | Type | Amount |
|---|---|---|
| Aug 3, 2023 | Payment Denial | - |
| Mar 16, 2023 | Fine | $227K |
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Frequently Asked Questions
What is the overall CMS rating for AVENTURA AT PEMBROOKE?
What are the staffing levels at AVENTURA AT PEMBROOKE?
How many beds does AVENTURA AT PEMBROOKE have?
Does AVENTURA AT PEMBROOKE have any deficiencies on record?
Has AVENTURA AT PEMBROOKE received any fines or penalties?
Who owns AVENTURA AT PEMBROOKE?
When was AVENTURA AT PEMBROOKE last inspected?
What quality measures are tracked for AVENTURA AT PEMBROOKE?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.