Cycle 1
Health 2025-08-22 · Fire 2024-07-25
17 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
West Chester, PA
Aventura At Pembrooke
1-star overall rating with 1-star inspections with 17 recent health deficiencies
1130 West Chester Pike, West Chester, PA
(610) 692-3636
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aventura Health Group
Operator or chain grouping
Approved since
1976-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,904
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.16
Baseline 20.92% · Performance 19.50% · Measure score 4.16 · Achievement 4.16 · Improvement 3.13
Healthcare-associated infections
0
Baseline 7.00% · Performance 8.44% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.23
Baseline 60.75% · Performance 54.55% · Measure score 2.23 · Achievement 2.23 · Improvement 1.23
Adjusted total nurse staffing
2.45
Baseline 3.50 hours · Performance 3.77 hours · Measure score 2.45 · Achievement 2.45 · Improvement 0.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.19% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 17.07% · Lower 95% interval 8.22% |
| Discharge to community | 38.57% |
50.57%
12 pts worse
|
Worse than the National Rate · Eligible stays 87 · Observed rate 21.84% · Lower 95% interval 27.2% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 80 · Denominator 80 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 80 |
| Discharge self-care score | 70.37% |
53.69%
16.7 pts better
|
Numerator 38 · Denominator 54 |
| Discharge mobility score | 42.59% |
50.94%
8.3 pts worse
|
Numerator 23 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 5 · Denominator 80 · Adjusted rate 4.86% |
| Healthcare-associated infections requiring hospitalization | 8.44% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 15.52% · Lower 95% interval 4.7% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 5% |
42%
37 pts worse
|
Numerator 14 · Denominator 280 |
| Discharge function score | 57.41% |
56.45%
1 pts better
|
Numerator 31 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.84% |
25.2%
11.6 pts better
|
Numerator 14 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.7
1.2 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
86.9%
3.6 pts better
|
93.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.8% · Q2 92.7% · Q3 96.5% · Q4 92.6% · 4Q avg 90.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
93.5%
5 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 2.6% · Q4 4.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
6.5%
2.9 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 4.0% · Q4 3.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.5%
2.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 3.6% · Q3 2.8% · Q4 1.8% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
19.9%
5.2 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.8% · Q3 15.3% · Q4 15.5% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
18.7%
1.9 pts worse
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 17.8% · Q3 20.0% · Q4 21.6% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.2% |
19.6%
13.4 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.9% · Q3 0.0% · Q4 10.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
18.3%
12.1 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.5% · Q3 6.7% · Q4 7.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
26.4%
11 pts better
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 5.1% · Q3 9.9% · Q4 23.6% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.3%
2.2 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.9% · Q3 3.8% · Q4 7.7% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.3% |
68.9%
21.6 pts worse
|
81.7%
34.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 37.8% · Q3 48.4% · Q4 60.7% · 4Q avg 47.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
9.8%
9 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 22.7% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.8% |
68.7%
10.9 pts worse
|
79.7%
21.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.9% |
23.1%
6.8 pts worse
|
23.9%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 36.4% · Expected 29.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-25 · Fire 2023-09-08
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-09-08 · Fire 2022-10-14
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
L · Immediate jeopardy
2025-12-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-21
F · Potential for more than minimal harm
2025-12-28
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-21
G · Actual harm
2025-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-18
G · Actual harm
2025-11-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-11-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-11-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-18
E · Potential for more than minimal harm
2025-08-22
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-08-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-08-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-08-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-08-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-08-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-29
D · Potential for more than minimal harm
2024-07-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-25
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-25
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-06-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-09-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-05
E · Potential for more than minimal harm
2023-09-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-08
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-08-03
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-08-28
J · Immediate jeopardy
2023-03-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-29
J · Immediate jeopardy
2023-03-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-03-16
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-03-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-29
Penalties and ownership
What sits behind the stars
$0
2023-08-03
Payment Denial
Payment Denial · denial start 2023-11-03 · 2 days
2 day denial
Ownership
Cpp Senior Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Kaszirer, Moishe
5% Or Greater Indirect Ownership Interest · Individual
Kaszirer, Moishe
Operational/Managerial Control · Individual
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