NursingHomeGrade

AVENTURA AT PEMBROOKE

1130 WEST CHESTER PIKE, WEST CHESTER, PA 19380

Operator

CPP SENIOR HOLDINGS · 3 facilities

Provider number (CCN)
395166
Certification
Medicare and Medicaid
Ownership
For profit - Corporation
Certified beds
180
Phone
(610) 692-3636
CMS data as of
August 1, 2026
F
●
stable

Staffing 0% · Deficiencies 0% over tracking period

What the records show

CMS rates AVENTURA AT PEMBROOKE 1 out of 5 stars overall, with 1 of 5 for health inspections, 2 of 5 for staffing, 2 of 5 for quality measures. Federal inspectors cited 31 health deficiencies across the last three survey cycles, most recently surveyed in 2025, 3 at actual-harm level or higher. CMS enforcement records list 1 fine totalling $55,416.

Facility Assessment Inspectors recorded 3 citations at the actual-harm level or worse in the last three survey cycles. This facility is operated by CPP SENIOR HOLDINGS, which scores 33 points below the national average. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.

Reviews, Ratings and Official Records

This page reviews AVENTURA AT PEMBROOKE using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.

Below the repealed 0.55 hr benchmark — review the inspection and enforcement records below for the safety history behind the grade.

Ratings and Grade Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
 0.41 — Below the repealed 0.55 hr benchmark

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 31
Outstanding 0
Actual harm or worse (G–L) 3
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
Overall: ★☆☆☆☆ (1/5)
Health inspection: ★☆☆☆☆ (1/5)
Quality: ★★☆☆☆ (2/5)
Staffing: ★★☆☆☆ (2/5)
NursingHomeGrade Score
 13/100

Loaded into NursingHomeGrade on September 5, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.

Staffing Compared With State and National Levels

This facility0.41 hrs
PA median0.66 hrs
National average0.69 hrs

Staffing figures are the values CMS published in its file processed August 1, 2026, drawn from payroll-based journal reporting.

Inspection Records Covered

Source records: CMS Care Compare profile for provider 395166 ↗ · the federal files we load and when.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

1 immediate jeopardy, 2 actual harm issues found among 31 total deficiencies. 31 corrected.

Most recent inspection (December 28, 2025)

F Potential harm — widespread F0835 Status: Corrected

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies — Deficient, Provider has date of correction, corrected January 21, 2026

D Potential harm — isolated F0770 Status: Corrected

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies — Deficient, Provider has date of correction, corrected January 21, 2026

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 21, 2026

D Potential harm — isolated F0757 Status: Corrected

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 29, 2025

D Potential harm — isolated F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2026

L Immediate jeopardy — widespread F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 21, 2026

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 21, 2026

D Potential harm — isolated F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 21, 2026

G Actual harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2025

G Actual harm — isolated F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2025

D Potential harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2025

E Potential harm — pattern F0693 Status: Corrected

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 29, 2025

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 29, 2025

D Potential harm — isolated F0690 Status: Corrected

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 29, 2025

D Potential harm — isolated F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 29, 2025

D Potential harm — isolated F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2025

D Potential harm — isolated F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 29, 2025

D Potential harm — isolated F0842 Status: Corrected

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 29, 2025

Inspection cycle 2 (July 25, 2024)

D Potential harm — isolated F0758 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 16, 2024

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 16, 2024

D Potential harm — isolated F0825 Status: Corrected

Provide or get specialized rehabilitative services as required for a resident.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 16, 2024

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 16, 2024

Inspection cycle 3 (September 8, 2023)

D Potential harm — isolated F0756 Status: Corrected

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 5, 2023

D Potential harm — isolated F0757 Status: Corrected

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 5, 2023

D Potential harm — isolated F0758 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 5, 2023

D Potential harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 5, 2024

E Potential harm — pattern F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 5, 2023

E Potential harm — pattern F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 5, 2023

D Potential harm — isolated F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024

D Potential harm — isolated F0655 Status: Corrected

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 5, 2023

D Potential harm — isolated F0567 Status: Corrected

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 28, 2023

Fines and Enforcement Actions

Penalties CMS has imposed on this facility. A fine is a civil money penalty; a payment denial suspends Medicare or Medicaid payment for new admissions.

Date Action Amount or length
December 28, 2025 Fine $55,416

1 fine totalling $55,416.

Source: CMS Penalties file (dataset g6vv-u9sr).

Ownership and Contact Information

Facility name
AVENTURA AT PEMBROOKE
Legal business name
AVENTURA AT PEMBROOKE LLC
Address
1130 WEST CHESTER PIKE, WEST CHESTER, PA 19380
Phone
(610) 692-3636
Provider number (CCN)
395166
Ownership type
For profit - Corporation
Operator
CPP SENIOR HOLDINGS · 3 facilities
Medicare/Medicaid certified since
December 1, 1976
Official record
CMS Care Compare profile ↗
Details verified against CMS data dated
August 1, 2026

The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.

How We Stay Independent

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Learn about our data methodology →

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Sources and Methodology

The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.

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