Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Envive Of Brookville during CMS and state inspections, most recent first.
A resident with CHF, diabetes, COPD, and morbid obesity had a physician order for daily weights, but the record showed weights were documented only sporadically and most missed weights had no refusal documentation or provider notification. Staff interviews showed confusion about whether the order was active, and the DON stated the resident had a history of noncompliance with weights, fluid restrictions, medications, and treatments.
Missing COVID-19 Vaccine Education and Documentation: The facility failed to document COVID-19 vaccine education, offer, and vaccination status for five residents reviewed. Records for residents with diagnoses including COPD, HTN, diabetes, CKD, and emphysema did not show education, acceptance, or refusal for the 2025-2026 COVID-19 vaccine. The IP stated the vaccine was offered yearly, but the DON confirmed there was no documentation for these residents and that consent forms were no longer included in the admission packet.
Failure to provide ordered feeding assistance: A resident with dementia, dysphagia, and eating difficulties had severe cognitive impairment, weight loss, and was ordered to receive 1:1 feeding on the left side with an upright posture and slow, small bites and sips. Staff were observed feeding the resident from the wrong side during one meal and later leaving the resident alone to self-feed in the dining room without assistance or observation, despite the resident’s documented need for help with utensils and swallowing.
Improper Storage of Respiratory Supplies at Bedside: A resident with COPD had an oxygen nebulizer, tubing, and mask left openly on an empty bed, with the mask not stored in a bag and later covered by a blanket. The resident said the equipment usually stayed on the bed close to her and that she received breathing treatments twice daily. The DON stated the supplies should be kept in a bag at the bedside, and the facility respiratory policy required oxygen cannula and tubing used PRN to be kept in a plastic bag when not in use.
A resident with COPD and nicotine dependence was seen for dental concerns and reported holes in his teeth and pain when chewing on one side. A dental consult recommended a specific rechargeable toothbrush and water flosser and referred him to an oral surgeon for two tooth extractions, but the record showed no follow-up on the oral hygiene items or the oral surgeon appointment, and the resident said no one had contacted him about either.
Delayed response to call lights led to a dignity deficiency for two residents. One cognitively intact resident with obstructive uropathy and weakness waited over an hour for toileting help and became incontinent of bowel, feeling uncomfortable and embarrassed. Another cognitively intact resident with MS, chronic pain, and bladder dysfunction waited about an hour for repositioning after reporting severe discomfort; a CNA said she did not have time and left before returning later to assist.
Misappropriation of Resident Narcotic Medication: A resident with chronic pain and an order for PRN Percocet had a sleeve of 6 tablets disappear from the locked narcotic box along with the narcotic sheet. RN 2 had received and secured the medication, but later an LPN found it missing during a pain-medication request. Interviews and record review showed RN 3 was the last nurse caring for the resident, claimed to have given pills overnight, but there was no MAR or PCC documentation and the resident denied receiving the medication.
The facility failed to ensure treatments were completed and documented on the night shift for several residents, leading to deficiencies in care. A resident with Parkinson's disease suffered a fall due to lack of protective gear, and other residents did not receive necessary treatments as per their care plans. The issue was exacerbated by night shift nurses' lack of access to the treatment administration record (TAR) due to a security issue with the electronic health record (EHR) system.
The facility failed to monitor and document target behaviors for five residents prescribed unnecessary medications. Residents with conditions such as depression, anxiety, and insomnia were not monitored on the night shift due to a transition to a new EHR system, which restricted access to the TAR. Interviews with the DON and CNO revealed that the issue was not identified until late February, despite the expectation that physician's orders are followed.
The facility failed to monitor psychotropic medication side effects for several residents during the night shift due to a transition between electronic health record systems, leaving nurses without access to necessary documentation. This affected residents with various diagnoses, including depression, anxiety, and dementia, who were prescribed medications like sertraline and alprazolam.
The facility failed to provide palatable and attractive meals to residents, as evidenced by multiple complaints about the food being bland, mushy, and unappetizing. Residents reported dissatisfaction with meals, often opting for alternative food options. A test tray confirmed the lack of flavor and poor presentation of the meals. The Dietary Manager acknowledged resident concerns, particularly after a recent menu change.
A resident with flaccid hemiplegia and dysphagia did not receive the necessary adaptive eating equipment, such as a plate guard and specialized cup, as per physician's orders. The facility was missing specialized utensils, and the Dietary Manager acknowledged the shortage. Despite the resident's care plan and facility policy requiring adaptive devices, the resident did not receive the required equipment.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, despite the resident's medical history of chronic kidney disease, ESBL resistance, and urinary tract infections. Staff interviews revealed a lack of awareness and implementation of EBP, with standard precautions being used instead. An observation showed that the EBP container in the resident's room was improperly used for storage, and staff were unaware of its presence, contrary to the facility's policy on EBP.
Failure to Document Ordered Daily Weights
Penalty
Summary
The facility failed to routinely document physician-ordered daily weights for Resident B, who had diagnoses including CHF, diabetes, COPD, and morbid obesity. His MDS assessment indicated he was cognitively intact, non-ambulatory, and used a wheelchair for mobility. The current order summary showed an order placed for daily weights, but the order did not include parameters for notifying the physician for weight gain or loss within a defined time period. Weights were documented only on a few dates in the clinical record, and the majority of dates without weights had no documentation showing that the resident refused the weight or that the attending physician or NP was notified that the weight was not obtained. During interview, Resident B denied that daily weights had ever been obtained at the facility. An LPN stated she was unaware of any current residents who were to have daily weights, while another LPN identified Resident B as the resident with that order. The DON stated Resident B had a history of noncompliance with care, including refusing daily weights, and said the doctor and NPs were aware of his noncompliance with fluid restrictions, weights, medications, and treatments. The RD stated she believed the daily weight order had been discontinued after the resident signed a waiver for fluid restrictions and noted he was noncompliant with many aspects of care, including refusing weights at times. The facility later provided policies on weight assessment and provider notification, which stated that resident weights were to be monitored and recorded and that the physician or practitioner was to be informed of diagnostic results or changes in condition in a timely manner. The DON also stated the facility did not have a specific policy or procedure regarding implementation of physician orders and that the expectation was that all physician orders were followed.
Missing COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to educate residents and staff on the 2025-2026 COVID-19 vaccination, offer the vaccine to eligible residents and staff after education, and maintain documentation of each resident's vaccination status for 5 of 5 residents reviewed. The clinical records for Residents 3, 7, 9, 10, and 12 did not contain 2025-2026 COVID-19 vaccination information showing that each resident accepted or refused the vaccine or received education about it. The residents reviewed had diagnoses including COPD, hypertensive heart disease with heart failure, diabetes, hypertension, chronic kidney disease, and emphysema. Resident 3's record showed diagnoses of COPD and hypertensive heart disease with heart failure and an admission date listed as [DATE], but there was no documentation of COVID-19 vaccination education, acceptance, or refusal for the 2025-2026 season. Resident 7's record showed diabetes and hypertension, Resident 12's record showed COPD and chronic kidney disease, Resident 10's record showed COPD and hypertension, and Resident 9's record showed emphysema and hypertension; each record lacked documentation indicating that the resident was provided education regarding the vaccination or that the vaccine was accepted or refused. The Infection Preventionist stated that the facility offered the COVID-19 vaccination to all residents on a yearly basis and provided the CDC Fact Sheet at that time. The DON stated there was no documentation showing the five residents were offered the 2025-2026 COVID-19 vaccination or that staff provided education on the vaccination, and that the facility had previously included vaccination consents in the admission packet but no longer did so. The facility policy stated residents and/or resident representatives and staff were to be educated on the COVID-19 vaccine, provided the FDA fact sheet before being offered the vaccine, and have documentation in the medical record showing education and whether the vaccine was accepted, received, refused, or not given for a medical reason.
Failure to Provide Ordered Feeding Assistance
Penalty
Summary
The facility failed to assist a resident with feeding despite the resident’s documented need for 1:1 feeding support and a physician order directing feeding on the left side, in an upright position, with small bites and sips at a slow rate. Resident 8 had diagnoses including dementia, epilepsy, dysphagia, eating difficulties, and schizoaffective disorder. The quarterly MDS indicated severe cognitive impairment, partial/moderate assistance was needed to bring food and/or liquid to the mouth and swallow, and the resident had loss of food or liquids from the mouth, food held in the mouth/cheeks after meals, and coughing or choking during meals or when swallowing medications. The EHR showed a 9.15% weight loss from 12/29/25 to 3/16/26, and a nutritional risk assessment identified the resident as at risk for malnutrition and receiving supplements due to weight loss. During observation, the resident was seen being fed pureed food by the Social Service Director, who was positioned to the resident’s right, despite the order for left-side feeding. On later observations, the resident was seated alone in the dining room with a pureed tray and was feeding himself without staff assistance or observation. On one occasion, the resident had difficulty lifting a two-handled cup to his mouth, and no staff were observed assisting him. The DON stated the resident was supposed to receive 1:1 feeding and assistance on the left side with all meals, and nursing was responsible for ensuring that assistance occurred for every meal.
Improper Storage of Respiratory Supplies at Bedside
Penalty
Summary
The facility failed to store respiratory supplies correctly at the bedside for Resident 21, who had diagnoses including COPD, hypothyroidism, and anxiety disorder and was cognitively intact on the Quarterly MDS assessment. During observation, the resident’s oxygen nebulizer with tubing and mask was found openly lying on an empty bed, and the oxygen mask was not in a bag. On a later observation, the nebulizer, oxygen tubing, and mask were again lying on the empty bed, covered with a blanket. Resident 21 stated that the nebulizer and mask usually always lay on the bed close to her and that she received breathing treatments twice a day, in the morning and at bedtime. The record included an order for Budesonide Suspension 0.25 mg/2 ml inhaled orally every 12 hours for COPD, and the care plan directed staff to give aerosol or bronchodilators as ordered. The DON stated that the nebulizer and supplies should all be in a bag at the bedside and that the tubing gets changed weekly. The facility respiratory policy stated to keep oxygen cannula and tubing used PRN in a plastic bag when not in use.
Failure to Follow Up on Dental Referral and Oral Hygiene Recommendations
Penalty
Summary
The facility failed to provide dental services for one resident by not scheduling a referred oral surgeon appointment and not following up on a dental recommendation for a new rechargeable toothbrush and water flosser. Resident 12’s clinical record showed diagnoses including COPD and nicotine dependence. During an interview, he stated he needed to see the dentist because he had holes in his teeth and believed an appointment had already been scheduled. The dental consultation dated 3/18/26 recommended a specific rechargeable toothbrush and water flosser and referred the resident to a specific oral surgeon for extraction of two teeth. The record contained no evidence that the toothbrush and water flosser recommendation was followed up on or that an oral surgeon appointment was scheduled. The resident later stated that no one had followed up with him about the extractions or the new toothbrush and water flosser, and he wanted the extractions completed. He also indicated that his teeth hurt when he chewed on the right side of his mouth, so he avoided chewing on that side.
Delayed Response to Call Lights Resulted in Resident Incontinence and Unmet Needs
Penalty
Summary
The facility failed to ensure residents maintained dignity by answering call lights in a timely manner for two residents who needed assistance with toileting or repositioning. One resident with obstructive uropathy and weakness was cognitively intact, frequently incontinent of bowel, and required moderate assistance with toileting. The resident reported turning on the call light to use the bathroom and waiting over an hour for help, after which the resident became incontinent of bowel and felt uncomfortable and embarrassed. Another resident with multiple sclerosis, generalized anxiety disorder, chronic pain syndrome, and neuromuscular dysfunction of the bladder was cognitively intact, used a wheelchair, and depended on staff for transfers and bed mobility. The resident reported turning on the call light because of severe discomfort and needing to be repositioned, but a CNA entered after about 20 minutes, said she did not have time because her partner was on break, and left the room. The resident then waited about 40 more minutes before staff returned to help, for a total wait of about an hour before the resident's needs were addressed.
Misappropriation of Resident Narcotic Medication
Penalty
Summary
The facility failed to ensure a resident’s right to be free from misappropriation of narcotic medication when a sleeve of 6 Percocet tablets belonging to a cognitively intact resident with chronic pain syndrome, irritable bowel syndrome, and idiopathic chronic gout was found missing from the narcotic box. The resident had an order for Percocet 5-325 mg every 8 hours as needed for neck pain and was documented as having frequent pain that occasionally interfered with daily activities. The resident’s January MAR indicated no Percocet was administered during the night or early morning surrounding the incident. According to the record and interviews, RN 2 received the 6 Percocet tablets from the pharmacy, signed for them, placed them in the locked narcotic box, and completed a narcotic sheet. RN 2 reported that a narcotic count and handoff with RN 3 at the end of the shift were correct. Later, when the resident called out for pain medication, LPN 4 found that the Percocet and the narcotic sheet were missing from the cart and binder. The Administrator and DON were notified, and the facility searched medication carts, med rooms, and the nurse’s station without finding the medication. The Administrator and DON stated RN 3 was the last nurse caring for the resident when the count changed from correct to incorrect. RN 3 told them she had given two pills overnight, but there was no documentation of administration or pain assessment, and the resident told the Administrator she had not taken any pain medication that night. LPN 4 stated RN 3 did not enter the medication in PCC and that the handoff sheet reflected 10 narcotic cards when there should have been 11 after the pharmacy delivery. Based on the investigation and narcotic audits, the facility concluded RN 3 was taking the medication and terminated her.
Deficiencies in Night Shift Treatment Documentation and Care
Penalty
Summary
The facility failed to ensure that treatments were completed and documented on the night shift for several residents, leading to deficiencies in care. Resident 7, diagnosed with Parkinson's disease, suffered a fall from his wheelchair, resulting in significant injuries. Despite a care plan intervention requiring the use of hipsters/padded undergarments to prevent falls, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of this requirement, and the resident was not wearing the necessary protective gear. Additionally, the treatment administration record (TAR) for February 2025 indicated that essential monitoring and treatments, such as applying barrier cream and floating heels, were not performed during the night shift. Resident 9, with diagnoses including peripheral vascular disease and COPD, had a care plan that required various interventions to prevent skin breakdown and ensure optimal breathing patterns. However, the February 2025 TAR showed that these interventions, such as applying moisture barrier and skin prep, elevating the head of the bed, and monitoring for signs of bruising and bleeding, were not documented as completed during the night shift. Similar issues were found with Resident 36, who was at risk for skin alterations, and Resident C, who required catheter care and other treatments, none of which were documented as completed on the night shift. The facility's failure to document and complete necessary treatments extended to Resident 24 and Resident G, both of whom had specific physician orders that were not followed during the night shift. Interviews with the DON, Chief Nursing Officer (CNO), and Qualified Medication Aides (QMAs) revealed that the night shift nurses did not have access to the TAR due to a security issue when transitioning to a new electronic health record (EHR) system. This lack of access resulted in the absence of documentation and completion of required treatments, highlighting a significant deficiency in the facility's care processes.
Failure to Monitor and Document Target Behaviors for Residents on Night Shift
Penalty
Summary
The facility failed to monitor and document target behaviors for five residents who were prescribed unnecessary medications. Resident 7, diagnosed with depression and insomnia, had a care plan requiring monitoring of behaviors related to these conditions. However, the treatment administration record (TAR) for February 2025 showed that the required monitoring was not conducted on the night shift throughout the month. Similarly, Resident 9, with diagnoses including depression, anxiety, and mood disturbance, was not monitored for behaviors related to these conditions on the night shift, as indicated in the February 2025 TAR. Resident 36, who had Parkinson's disease, anxiety disorder, and depression, was also not monitored for target behaviors related to psychotropic medications on the night shift, as per the February 2025 TAR. Resident C, with depression and anxiety disorder, was not monitored for target behaviors of psychotropic medications on the night shift, as indicated in the February 2025 TAR. Resident G, diagnosed with dementia and peripheral vascular disease, was prescribed medications for mood and behaviors, but the TAR indicated no monitoring of behaviors on the night shift from February 1 to February 25, 2025. Interviews with the Director of Nursing (DON) and the Chief Nursing Officer (CNO) revealed that the night shift nurses did not have access to the TAR due to a transition from one electronic health record (EHR) system to another, which occurred on January 1, 2025. This transition resulted in a security issue that prevented night shift nurses from seeing the TAR, although they could access the medication administration record (MAR). The CNO acknowledged that the issue was not identified until February 26, 2025, and emphasized the expectation that physician's orders are followed as a standard of care.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor for side effects of psychotropic medications as ordered for five residents. Resident 7, diagnosed with depression, was prescribed sertraline, and the care plan required monitoring for side effects every shift. However, the treatment administration record (TAR) for February 2025 showed no monitoring was done during the night shift for the entire month. Resident 9, with diagnoses including depression, anxiety, and dementia, was prescribed alprazolam and sertraline. The care plan required monitoring for side effects every shift, but the February 2025 TAR indicated no monitoring was done on the night shift. Similarly, Resident 36, diagnosed with Parkinson's disease, anxiety disorder, and depression, was prescribed antianxiety and antidepressant medications. The February 2025 TAR showed no documentation of side effect monitoring during the night shift. Resident C, with depression and anxiety disorder, was also not monitored for side effects during the night shift in February 2025, despite the care plan's requirements. Resident G, diagnosed with dementia and peripheral vascular disease, was prescribed divalproex sodium, sertraline, and aripiprazole, with orders for side effect monitoring every shift. However, the TAR indicated no monitoring was done on the night shift. The Director of Nursing and Chief Nursing Officer acknowledged the issue, attributing it to a transition between electronic health record systems that left night shift nurses without access to the TAR.
Facility Fails to Provide Palatable and Attractive Meals
Penalty
Summary
The facility failed to provide a diet that was palatable and attractive to nine residents, as evidenced by interviews, observations, and record reviews. Residents consistently reported that the food was unappetizing, bland, and often mushy. For instance, Resident 36, who is cognitively intact and has Parkinson's disease, expressed dissatisfaction with the meals, describing them as terrible and often opting for peanut butter and jelly sandwiches or candy brought by family instead. A test tray of the facility's lunch meal, which included a frittata, diced potatoes, broccoli, and a roll, was found to be unappealing, with three out of four items being yellow in color and lacking flavor. Resident 14 also reported dissatisfaction with the food, stating that the lunch meal was not good, and he did not eat the potatoes or the roll. Similarly, Resident 30 described the food as horrible, with the frittata having no taste and the broccoli being dull and flavorless. Resident 37 echoed these sentiments, indicating that the food was of poor quality and not fit to eat. Resident J, who is not a picky eater, found the food horrendous and inedible, leading her to go to bed hungry on multiple occasions. The Dietary Manager acknowledged that residents had voiced concerns about the food, particularly after a menu change on January 1, 2025. The manager noted an increase in requests for alternative foods since the menu change. The facility's General Food Preparation and Handling policy states that all food should be prepared to preserve nutritive value, flavor, and appearance, and be served attractively at the appropriate temperature. However, the observations and resident interviews indicate that the facility failed to meet these standards, resulting in a deficiency related to the quality and palatability of the food served.
Failure to Provide Adaptive Eating Equipment for Resident
Penalty
Summary
The facility failed to provide the necessary adaptive eating equipment for Resident 29, who was observed eating lunch without the required plate guard and specialized cup with a handle. Resident 29, who has flaccid hemiplegia affecting the left side and dysphagia, was noted to have a curved spoon, regular fork, and regular dinner plate, contrary to the physician's order for a plate guard, independence cup with handle, and adaptive utensils. The resident's clinical record indicated a need for a mechanically altered diet, and the MDS assessment confirmed mild cognitive impairment. Interviews with staff revealed that the facility was missing specialized utensils, and the Dietary Manager acknowledged the shortage and the need to order more. The Dietary Manager also confirmed that dietary staff receive nursing orders for specialized utensils, which are printed on the resident's tray card. Despite this, Resident 29 did not receive the necessary equipment, and the Director of Nursing provided a care plan indicating the need for adaptive equipment. The facility's policy on assistance with meals stated that adaptive devices should be provided to residents who need them, but this was not adhered to in Resident 29's case.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device, specifically a urinary catheter. Resident C, who was cognitively intact and had medical diagnoses including chronic kidney disease, ESBL resistance, and urinary tract infections, was not provided with the necessary EBP during catheter care. The care plan for Resident C indicated the use of an indwelling urinary catheter for obstructive uropathy, with interventions including catheter care every shift. However, during an interview, Resident C reported that staff did not use gowns when assisting with catheter care. Confidential interviews with staff revealed a lack of awareness and implementation of EBP for Resident C. One staff member indicated they were unaware of who was on transmission-based precautions and only used standard precautions, including gloves, for Resident C's care. Another staff member was not aware that Resident C was on EBP and did not utilize EBP during care activities such as bed baths and catheter care. An observation showed that the EBP container in Resident C's room was improperly used for storage, and staff were unaware of its presence. The facility's policy on EBP, provided by the Assistant Director of Nursing, stated that EBP should be used for residents with indwelling medical devices to prevent the spread of MDROs, but this was not followed in practice.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brookville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Knolls Of Oxford | 10.7 mi | ★★★★★ | 3 | 0 |
| Envive Of Liberty | 12.7 mi | ★★★★★ | 11 | 0 |
| Heritage House Rehabilitation & Health Care Center | 14.9 mi | ★★★★★ | 7 | 0 |
| Woodland Country Manor Inc | 15.3 mi | ★★★★★ | 12 | 0 |
| Harrison Trail Health Campus | 15.5 mi | ★★★★★ | 3 | 0 |
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