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Nursing HomeMedicaid Investigative

Aventura at Pembrooke

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1130 West Chester Pike, West Chester, PA 19380180 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.0/5

based on 181 Google reviews

5
4
3
2
1
Aventura at Pembrooke Nursing Home in West Chester, PA — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (17 vs median 8.0)

Bottom 25% in PA · Below recommended RN staffing · Worst in AVENTURA HEALTH GROUP chain

Source: Medicare data

What this means for your family

Aventura at Pembrooke has a highly effective therapy department and a modern, renovated environment that many families appreciate. However, the facility suffers from recurring, serious reports of nursing neglect and poor communication. If you choose this facility, maintain a very active presence, visit at irregular hours, and ensure you have direct contact information for the administrator rather than relying on the general nursing station.

Google Reviews

Google Reviews

181 reviews on Google
Aventura at Pembrooke presents a highly polarized experience for families, with recent reviews highlighting significant improvements in facility aesthetics and staff dedication alongside persistent, severe reports of neglect. While many families praise the therapy team and specific staff members for compassionate care, others report critical failures including poor hygiene, unresponsive nursing staff, and communication breakdowns. Prospective families should be aware that experiences appear to vary drastically depending on the specific unit and shift.

Quality Themes

Tap a score for details
Food4.0Staff5.0Clean3.0Activities8.0Meds2.0MemoryN/AComms2.0ValueN/A

Strengths

  • Effective physical and occupational therapy teams
  • Recent facility renovations and modern aesthetics
  • Dedicated concierge and administrative staff
  • Engaging activities and social programs

Concerns

  • Unresponsive nursing staff and delayed call-bell response (mentioned by 12 reviewers)
  • Poor hygiene and lack of cleanliness in resident rooms (mentioned by 9 reviewers)
  • Inadequate communication from administration and social services (mentioned by 8 reviewers)
  • Inconsistent or poor quality of food service (mentioned by 5 reviewers)

Rating Trends

Tap a year to see what changed

234'14(1)'17(3)'19(7)'21(5)'23(14)'25(43)'26(13)

Distribution · 138 analyzed

5
91
4
5
3
2
2
4
1
36

How They Respond to Reviews

23%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1Given the recent facility renovations, what specific steps are being taken to ensure that the high standard of cleanliness in common areas is consistently maintained inside individual resident rooms?
  • 2I noticed that the therapy teams are highly regarded here; how do you coordinate that care with the nursing staff to ensure residents receive timely assistance when they need it most?
  • 3Could you walk me through your current process for call-bell response times and how you ensure that residents' needs are addressed promptly during peak hours?
  • 4With the recent focus on social programs, what are some of the most popular activities that encourage residents to engage with one another throughout the week?
  • 5We understand that communication is key; what is the best way for family members to stay updated on their loved one's care plan and daily well-being?
  • 6How do you manage the dining experience to ensure that meals are both nutritious and served at the proper temperature for all residents?

Personalized based on this facility's data


Key Review Excerpts

The nursing team is compassionate, attentive, and consistent and sincere. It’s rare to find a place where you feel not only supported clinically, but truly embraced as family.

Long-term resident's family · 2025★★★★★

My mom is a patient here and I would NEVER recommend THIS DUMP. The social workers lied time and time again about things they already knew the answer to, and they never returned any of my calls.

Resident's family member · 2025☆☆☆☆

They left My mother sitting in her own feces for days, which led to her constantly catching C-diff and infections, due to the staffs negligence.

Resident's family member · 2022☆☆☆☆
Source: 181 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.49hrs
65%
Registered nurses for medical care
Total Nursing
3.65hrs
89%
All nurses + aides combined

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
2/ 5
Better Than Avg

11

measures

Worse Than Avg

5

measures

Mixed Results

1

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility13.4%
Better than Avg
Here
13.4%
US
19.4%
PA
26.0%
Chester
31.1%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility92.8%
Mixed vs Avgs
Here
92.8%
US
93.4%
PA
87.1%
Chester
76.9%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility4.2%
Better than Avg
Here
4.2%
US
15.3%
PA
18.4%
Chester
14.7%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.1%
Better than Avg
Here
7.1%
US
14.4%
PA
17.6%
Chester
18.9%
😔

Residents with depression symptoms

↓ Lower is better
This Facility2.9%
Better than Avg
Here
2.9%
US
12.1%
PA
8.3%
Chester
9.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility21.1%
Worse than Avg
Here
21.1%
US
15.4%
PA
17.8%
Chester
13.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility48.4%
Worse than Avg
Here
48.4%
US
81.8%
PA
69.2%
Chester
59.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility57.8%
Worse than Avg
Here
57.8%
US
79.7%
PA
68.7%
Chester
63.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.6%
Worse than Avg
Here
1.6%
US
1.6%
PA
1.4%
Chester
1.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
1penalties
Well above state avg (10.1)
16 complaint-triggered

This facility shows concerning patterns with 19 complaint-triggered deficiencies out of 34 total, indicating families have repeatedly filed reports about care issues. The most recurring problems involve treatment and care delivery, accident prevention and safety hazards, and care planning. Recent complaints in late 2024 and 2025 suggest ongoing issues with safety supervision, treatment quality, infection control, and respiratory care, though the facility has provided correction dates for all deficiencies.

Mar 26, 2026Complaint
1
0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Dec 28, 2025Complaint
6
0689Immediate jeopardy · WidespreadCorrected

Quality of Life and Care Deficiencies

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

0835Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0770Potential for harm · IsolatedCorrected

Administration Deficiencies

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

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nov 3, 2025Complaint
4
0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Aug 22, 2025Routine
7
0693Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

Jul 25, 2024Routine
4
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0825Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jun 27, 2024Complaint
1
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

Federal Penalties

Payment Denial

Aug 3, 2023

2-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Aventura at Pembrooke

Organization Type

for profit

Chain Affiliation

Chain Name

Aventura Health Group

Chain Size

12 facilities nationwide

Chain avg rating: 1.8/5 · Rank 11 of 11 (Worst)

Ownership & Management

Owners

Cpp Senior Holdings LLC

Owner · Organization

100%

Kaszirer, Moishe

Owner (parent company)

25%

Key personnel

Kaszirer, MoisheManagerBhatia, SanjayAdp of the SnfKleiner, ShloimeAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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