Aventura at Pembrooke

In the surveyor’s words

From the most serious findings on record at Aventura at Pembrooke, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Dec 28, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Mar 16, 2023

  Based on clinical record reviews, facility policy and facility documentation review, and staff interviews it was determined that the facility failed to ensure residents were free from abuse when staff failed to implement supervisory measures allowing Resident CL3 to physically assault and cause significant injuries to the head and upper extremities of Resident CL2, resulting in an immediate jeopardy situation. Findings include: Review of facility policy titled, Safety and Supervision of Residents without revision date under subheading, Individualized, Resident-Centered Approach to safety revealed Number 3 The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. […]

• Immediate jeopardy, isolatedF689Mar 16, 2023

  Based on clinical record reviews, facility policy and facility documentation review, and staff interviews it was determined that the facility failed to ensure to initiate or implement adequate supervisory measures for Resident CL3 to prevent life threatening injuries to CL2, resulting in an immediate jeopardy situation. Findings include: Review of facility policy titled, Safety and Supervision of Residents without revision date under subheading, Individualized, Resident-Centered Approach to safety revealed Number 3 The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. […]

• Immediate jeopardy, isolatedF689Apr 27, 2022

  Based on observations, clinical record reviews, facility documentation, policy and procedures, staff and resident interviews, it was determined that the facility failed to implement sufficient monitoring interventions, supervision, and effective safety measures to prevent elopement (unauthorized leave from a safe area) of a resident assessed with history of elopement and exit seeking behavior. This failure placed residents at the facility in an Immediate Jeopardy situation for one of nine residents reviewed who were identified as at risk for elopement (Resident R1). […]

• Actual harm, isolatedF684Nov 3, 2025

  Based 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.Findings include:Review of Resident R2's diagnosis list includes Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time), Peripheral Venous Insufficiency (condition that occurs when the veins in the legs do not function properly, leading to poor blood flow back to the heart), and non-pressure chronic ulcer (wound) of the right leg.Review of Resident R2's active care plan revealed actual skin integrity… […]