Home / Pennsylvania / West Chester
1130 West Chester Pike, West Chester, PA 19380 · Chester County · (610) 692-3636
180 certified beds, about 136 residents a day · For profit - Corporation · Medicare and Medicaid since 1976
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395166 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 29, 2026, inspectors cited 12 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
Of 38 health citations since September 2023, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $55,416 in the last three years; the largest was $55,416, and the latest is dated December 28, 2025.
Nurses and nurse aides worked 3.39 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.41 of those hours.
CMS links it to Aventura Health Group, an affiliated group of 11 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 38 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to provide and/or obtain informed consents for psychotropic medications for three of five residents reviewed for unnecessary medications (Resident 3, Resident 9, and Resident 154).
Inspectors wroteBased upon observation and interview, it was determined that the facility failed to ensure appropriate storage of dry goods, maintain appropriate concentration of sanitizing solutions, and maintain safe conditions within the facility's freezer. Observation of the facility's kitchen on July 26, 2026, at 9:35 a.m., reveals a buildup of ice accumulation on the PVC strip curtains at the entrance of the walk-in freezer. Further observation of the facility's kitchen on July 29, 2026, at approximately 2:00 p.m., finds containers of powder thickener and flour open to air. Observation during a tour of the facility's kitchen on July 29, 2026, at approximately 2:00 p.m., finds a bucket of liquid without a detectable level of sanitizer when tested with a pH strip, containing a cloth to wipe down tray delivery carts. [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain medication administration records that were accurate and complete for eight of eight residents reviewed (Residents 2, 5, 7, 10, 11, 15, 26, and 39).
Inspectors wroteBased upon observation and interview, it was determined that the facility failed to prevent accumulations of fruits flies in the kitchen. Observation during a tour of the facility's kitchen on July 29, 2026, at approximately 2:00 p.m., reveals several fruit flies observed throughout the kitchen. Fruit flies were observed inside and around open containers of powder thickener and flour. Interview with Nursing Home Administrator confirms the above findings. 28 Pa.
Inspectors wroteBased on observations, resident and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for three out of three floors (First, Second and Third floor).
Inspectors wroteBased on record review, the facility failed to ensure PRN (pro-re nata or as needed) orders for psychotropic medications are limited to 14 days for one out of two residents reviewed for unnecessary medications (Resident 154).
Inspectors wroteBased on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for four out of thirteen residents reviewed. (Resident 13, Resident 64, Resident 82 and Resident 123)
Inspectors wroteBased on record review, the facility failed to accurately assess a Resident's health status for one of eight residents reviewed (Resident 39).
Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to provide quality care for three of 28 residents reviewed (Resident 8, Resident 28, and Resident 82).
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the risk of accident by leaving patient medication unattended at the bedside for one out of eight residents reviewed (Resident 46).
Inspectors wroteBased upon clinical record review and interviews, it was determined that the facility failed to ensure that medication irregularities were appropriately acted upon by a physician for one of five residents reviewed (Resident 3).
Inspectors wroteBased on observation and record review, the facility failed to ensure that transmission-based precautions were adhered to for two of 27 residents reviewed (Resident 7 and Resident 72).
Inspectors wroteBased on observations and resident and staff interviews it was determined that the facility failed to provide hydration for residents on three of three floors. (1st, 2nd, and 3rd floors)
Inspectors wroteBased on observations, facility documentation review, as well as staff and resident interviews it was determined the facility failed to ensure water temperatures were maintained at a safe level in resident care areas for three of three units in the facility resulting in immediate jeopardy to the residents. (1st, 2nd and 3rd floors)Findings Include: Observation of the staff and visitor bathroom on the ground floor on December 23, 2025, at approximately 11:15 a.m. revealed while the surveyor was washing their hands the water was observed to be very hot, steaming, and left red mark covering approximately 50% of both hands after four seconds of exposure to the water. [...]
Inspectors wroteBased on the review of job descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of residents due to hot water temperatures. This failure resulted in an Immediate Jeopardy situation. Findings Include: Review of the job description for the Nursing Home Administrator (NHA) states position purpose: Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Further review of the NHA position description revealed the Essential Function: [...]
Inspectors wroteBased on clinical records review, and staff interview, it was determined that the facility failed to follow the medication ordered by the physician for one of three residents reviewed (Resident CL1).
Inspectors wroteBased on observations and staff interview it was determined the facility failed to label and date oxygen and suction tubing for two of two residents reviewed (Resident 1 and 2). Findings Include: Observations of Residents 1 and 2 on December 23, 2025 at 9:45 a.m. revealed both residents had a tracheostomy (a surgical procedure creating an opening (stoma) in the neck into the windpipe (trachea) to provide a direct airway for breathing, often using a tube, used for blockages, long-term ventilation, or secretion clearance) with a trach collar (a soft strap that secures a tracheostomy tube in place around the neck, preventing it from moving or dislodging, while also providing a way to deliver humidified oxygen or manage airflow directly to the airway opening) in place. Further observations revealed that both residents had suctioning set up at their bedside. [...]
Inspectors wroteBased on review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure laboratory tests for Urinalysis (A set of tests that looks at the appearance of the urine and checks for blood cells, proteins, and other substances in it) ordered by the physician were timely followed (Resident CL1).
Inspectors wroteBased on facility policy review, observations and staff interviews it was determined the facility failed to provide PPE and signage for residents who require enhanced barrier precautions for four resident rooms and one resident (115, 108, 104, 102, and Resident 2)Findings Include: Review of facility policy titled Infection Prevention and Control, effective February 24, 2025, revealed Use EPB (enhance barrier precautions) for residents with wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism).post notice outside the resident room when on EBP. Observations of rooms 102, 104, 108, and 115 on December 23, 2025, at 9:45 a.m. revealed hanging from each door was a storage system with PPE (Personal Protective Equipment) Sucha as gowns, gloves and mask. [...]
Inspectors wroteBased on observation, clinical record reviews, and staff interviews, it was determined the facility failed to follow a physician's order for two of five residents reviewed (Residents R1 and R2). Failure to follow Resident R2's wound care orders resulted in actual harm with deterioration of the wounds as evidenced by increased size.
Inspectors wroteBased on clinical record review, observation, staff and resident interviews, it was determined the facility failed to provide adequate supervision during resident care resulting in actual harm to Resident R1 who sustained a fall and an Acute Subarachnoid Hemorrhage (life-threatening condition where bleeding occurs in the space between the brain and the membrane that covers the brain) for one of five residents reviewed (Resident R1).
Inspectors wroteBased on review of the Pennsylvania Professional Nursing Practice Act, observation, clinical records review, and staff interview, it was determined the facility failed to maintain the professional standard of practice in providing wound care for one of three residents reviewed (Resident R2).
Inspectors wroteBased on observation, clinical records review, and staff interview, it was determined the facility failed to follow the wound treatment order for a sacral, Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) for one of three residents reviewed (Resident R2).
Inspectors wroteBased on facility policy review, clinical record review, and interview with staff it was determined that the facility failed to ensure that residents receiving enteral feeding (also known as tube feeding - method of delivering nutrition directly to the gastrointestinal tract when a person cannot eat safely or adequately by mouth) received the amount ordered by the physician for five of eight residents reviewed (Residents 3, 4, 5, 111, and 115). Review of Resident 3’s admission physician’s orders of July 8, 2025, indicated that the resident was NPO (nothing by mouth). Review of physician’s enteral feed order of July 10, 2025, revealed that the resident was to receive Glucerna 1.5 at 63 milliliters (mL) per hour for 20 hours for a total volume of 1260 ml. [...]
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to create a comprehensive hospice care plan with interventions for one of two residents reviewed (Resident 13).
Inspectors wroteNumber of residents sampled: Number of residents cited: Based upon clinical record review and interview, it was determined that the facility failed to ensure that physician orders were followed regarding fluid restrictions for two of four dialysis residents (Resident 2 and Resident 82).
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, review of facility policy, clinical record review and interview with staff, it was determined that the facility failed to ensure that appropriate catheter treatment and services were provided for one of three residents reviewed (Resident 3).
Inspectors wroteNumber of residents sampled: Number of residents cited: Based upon facility policy and procedure, clinical record review and interview, it was determined that the facility failed to ensure that an admission weight was accurately obtained and failed to ensure accurate weights were monitored for one of nine residents reviewed (Resident 4).
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on review of facility policy, clinical record review, and interview with staff, it was determined that the facility failed to implement non-pharmacological interventions prior to the administration of pain medication for one of two residents (Resident 3).
Inspectors wroteBased on facility clinical records review, and staff interviews, it was determined that the facility failed to correctly document the Medication Administration Report for one of 28 residents reviewed (Resident 1).
Inspectors wroteBased on observation, medical record review, and interviews with residents and staff, it was determined the facility failed to provide a dignified existence for 1 of 1 (Resident 98) by not allowing the resident to transfer to a more appropriate unit.
Inspectors wroteBased on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of medications for one of the 23 residents reviewed (Resident 69). Additionally, the facility failed to follow physician orders regarding referrals for one of the 23 residents reviewed (Resident 29).
Inspectors wroteBased on clinical record review, and observation, it was determined that the facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for one of five residents reviewed for unnecessary medications (Resident 6).
Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to provide therapy services to prevent a decline in Activity of Daily Living performance for one of 23 residents reviewed. (Resident 29) Findings Include: Review of Resident 29's clinical records revealed medical diagnosis that include Pleural Effusion (excess fluid between lungs and chest wall), Acute Kidney Failure (kidney failure), Parkinson's Disease (chronic and progressive movement disorder) and Rheumatoid Arthritis (inflammatory disease affecting the joints). Review of Resident 29's clinical records revealed a progress note dated July 1, 2024, stating the resident returned from Neurologist appointment with a prescription for Physical and Occupational Therapy. [...]
Inspectors wroteBased on clinical record review it was determined that the facility failed to develop a comprehensive care plan including discharge planning for one of three residents reviewed (Resident R1). Findings Include: Review of Resident R1's clinical record revealed diagnoses including but not limited to following: Depression (mood disorder that causes a persistent feeling of sadness and loss of interest); Epilepsy (neurological disorder that causes seizures or unusual sensations or behaviors), and Anxiety ( feeling of dread, fear, or apprehension, often with no clear justification). Review of Resident R1's clinical record revealed a progress note by CRNP (Certified Registered Nurse Practitioner) dated December 28, 2023 (13:39/1:39 p.m.) admitted to Pembrooke (facility) on 12/26/23 following discharge from [local hospital] for treatment of seizure activity. [...]
Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to comprehensively assess a wound identified upon admission and failed to place a treatment order timely for one of three residents reviewed (Resident CL1).
Inspectors wroteBased on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of medications for three of the 30 residents reviewed (Resident 9, 86, and 132).
Inspectors wroteBased on clinical record review and staff interviews it was determined that the facility failed to ensure residents are free from unnecessary drugs without adequate indications for its use for one of 32 residents (Resident 130).
| Date | Penalty | Amount or length |
|---|---|---|
| December 28, 2025 | Fine | $55,416 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.39 | 3.89 | 3.86 |
| Registered nurses | 0.41 | 0.79 | 0.69 |
| All nursing staff on weekends | 3.06 | 3.53 | 3.42 |
| Nurse aides | 1.96 | ||
| Licensed practical nurses | 1.02 | ||
| Nursing staff turnover (share who left in a year) | not reported | 44.5% | 45.8% |
| Registered nurse turnover | not reported | 39.9% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.21 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.52 on weekdays and 3.06 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 41.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.42 in July to September 2025 to 3.39 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.39 | 0.41 | 3.52 | 3.06 | 41.2% | 0 of 90 | 136 |
| Oct to Dec 2025 | 3.65 | 0.49 | 3.79 | 3.28 | 30.9% | 0 of 92 | 133 |
| Jul to Sep 2025 | 3.42 | 0.40 | 3.59 | 3.00 | 26.7% | 0 of 92 | 135 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Pennsylvania, Jan to Mar 2026 | 3.69 | 0.65 | 3.82 | 3.34 | 11.3% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Pennsylvania, all employers | |||
| CNAs (nursing assistants) | $21.44 | $18.88 to $22.52 | 67,740 |
| LPNs and LVNs | $30.74 | $29.02 to $35.01 | 38,260 |
| Registered nurses | $46.36 | $38.75 to $50.35 | 146,520 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 7.0 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.0 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 5.2 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 3.0 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.9 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 23.3 | 17.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 34.9 | 22.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 18.2 | 9.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.0 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Aventura at Pembrooke's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (38.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
38.6% this home
Worse than the national rate
US median of homes 51.5% · Pennsylvania: 100 better, 108 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 87 eligible stays.
11.2% this home
No different from the national rate
US median of homes 10.7% · Pennsylvania: 3 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 123 eligible stays.
8.4% this home
No different from the national rate
US median of homes 7.1% · Pennsylvania: 7 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 58 eligible stays.
54.4% this home
Median of homes: Pennsylvania54.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 57 residents counted.
1.4% this home
Median of homes: Pennsylvania0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 74 residents counted.
5.3% this home
Median of homes: Pennsylvania2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 74 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Pennsylvania100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 3 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: AVENTURA AT PEMBROOKE LLC. CMS links this home to Aventura Health Group, a group of 11 nursing homes averaging 1.6 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Cpp Senior Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 12/01/2018 |
| Kaszirer, Moishe | 5% or greater indirect ownership interest | Individual | 25% | 12/01/2018 |
| Kaszirer, Moishe | Operational/managerial control | Individual | 12/01/2018 | |
| Bhatia, Sanjay | Adp of the SNF | Individual | 02/03/2025 | |
| Kleiner, Shloime | Adp of the SNF | Individual | 01/28/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.