Aventura at Pembrooke

Name: Aventura at Pembrooke
Address: 1130 WEST CHESTER PIKE, West Chester, PA, 19380, US
Telephone: 6106923636

1130 West Chester Pike, West Chester, PA 19380 · Chester County · 180 certified beds · avg 136 residents/day · certified since Dec 1, 1976

Part of chain: AVENTURA HEALTH GROUP (11 facilities, chain avg rating 1.5★)

1/5

Health inspection rating (on-site)

Serious findings on record

$55,416

Fines, last 3 years

4.04

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, facility-wide · Dec 28, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.

Corrected: Jan 21, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Nov 3, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 18, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Nov 3, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 18, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (31)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Mar 26, 2026	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Dec 28, 2025	▲ L · Immediate jeopardy, facility-wide	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 28, 2025	F · Potential for harm, facility-wide	The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Dec 28, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 28, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Dec 28, 2025	D · Potential for harm, one-off	The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint
Dec 28, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Nov 3, 2025	▲ G · Actual harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 3, 2025	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 3, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Nov 3, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 22, 2025	E · Potential for harm, repeated	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Aug 22, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 22, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Aug 22, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Aug 22, 2025	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Aug 22, 2025	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Aug 22, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jul 25, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 25, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 25, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Jul 25, 2024	D · Potential for harm, one-off	The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
Jun 27, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Mar 21, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Sep 8, 2023	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 8, 2023	E · Potential for harm, repeated	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint
Sep 8, 2023	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Aug 3, 2023	D · Potential for harm, one-off	The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (4 → 7).

Year	Citations	Serious (G–L)	Worst severity that year
2023	7	0	E
2024	6	0	D
2025	17	3	L ▲
2026	1	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $55,416.

Date	Type	Amount / length
Dec 28, 2025	Fine	$55,416

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Pennsylvania avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.04	3.94	3.95	top 35% in Pennsylvania; top 38% in the U.S.
Registered Nurse hours	0.49	0.80	0.69	bottom 24% in Pennsylvania; bottom 36% in the U.S.
Weekend total nurse staffing	3.65	3.58	3.50	top 37% in Pennsylvania; top 35% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.23	0.56	0.48	bottom 7% in Pennsylvania; bottom 18% in the U.S.
Total nursing staff turnover (%)	0.0	44.5	45.8	—
RN turnover (%)	0.0	39.9	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.39, RN 0.41, weekend 3.06. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
CPP Senior Holdings LLC	Organization	5% or Greater Direct Ownership Interest	100%	12/01/2018
Kaszirer, Moishe	Individual	5% or Greater Indirect Ownership Interest	25%	12/01/2018
Bhatia, Sanjay	Individual	ADP of the SNF	NOT APPLICABLE	02/03/2025
Kaszirer, Moishe	Individual	Operational/Managerial Control	NOT APPLICABLE	12/01/2018
Kleiner, Shloime	Individual	ADP of the SNF	NOT APPLICABLE	01/28/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"What were the findings behind this administration citation, and what has leadership changed since?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"How quickly are lab tests done and results acted on when a resident's doctor orders them?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Barclay Friends	3.5 mi	West Chester, PA	★★★★☆	4/5
Park Lane Post Acute LLC	3.6 mi	West Chester, PA	★★★★★	4/5
HCC at White Horse Village	4.1 mi	Newtown Square, PA	★★★★★	5/5
West Chester Rehabilitation and Healthcare Center	4.3 mi	West Chester, PA	★★☆☆☆	2/5
Green Meadows Nursing & Rehabilitation Center	5.1 mi	Malvern, PA	★★★★☆	4/5
Brinton Manor Nursing and Rehabilitation Center	5.5 mi	Glen Mills, PA	★★★☆☆	3/5
Continuing Care at Maris Grove	6.0 mi	Glen Mills, PA	★★★★★	4/5
Willowbrooke Court-Granite	6.2 mi	Media, PA	★★★★★	5/5
Willowbrooke Court SKD Care Center at Lima Estates	6.8 mi	Lima, PA	★★★★★	5/5
Fair Acres Geriatric Center	6.8 mi	Lima, PA	★☆☆☆☆	2/5	abuse
Exton Post Acute	7.2 mi	Exton, PA	★★★☆☆	2/5
William Hood Dunwoody Care Ctr	7.8 mi	Newtown Square, PA	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in West Chester →

Facility data as of CMS processing date 2026-08-01. CCN 395166.

The Care File

Visit checklist — Aventura at Pembrooke

1130 West Chester Pike, West Chester, PA 19380 · 6106923636

Health inspection rating 1/5 · CMS overall 1/5· Fines (3y): $55,416

Most serious findings on record:

▲ Dec 28, 2025 (F-0689, Immediate jeopardy, facility-wide): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Nov 3, 2025 (F-0684, Actual harm, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
▲ Nov 3, 2025 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "What were the findings behind this administration citation, and what has leadership changed since?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "How quickly are lab tests done and results acted on when a resident's doctor orders them?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 395166 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)