Envive of Brookville

In the surveyor’s words

From the most serious findings on record at Envive of Brookville, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF887Mar 27, 2026

  Based on interview and record review, the facility failed to offer and provide education on the 2025-2026 Covid-19 vaccination and maintain documentation of such for 5 of 5 residents reviewed. (Residents 3, 7, 9, 10, and 12) Findings include: 1. The clinical record for Resident 3 was reviewed on 3/27/26 at 1:15 p.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease (a progressive, treatable lung disease, mainly caused by smoking or long-term irritant exposure, that restricts airflow and causes breathing difficulties) and hypertensive heart disease with heart failure (condition that occurs when chronic high blood pressure forces the heart to work harder, leading to thickened or weakened heart muscle that cannot pump effectively). […]

• No harm, potential for more than minimal, patternF684Feb 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure treatments were completed and documented on night shift and a resident had a fall intervention in place for 5 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for falls. (Residents C, G, 7, 9, 24, and 36) Findings include: 1. a) The clinical record 7 was reviewed on 2/25/25 at 12:47 p.m. His diagnoses included, but were not limited to, Parkinson's disease. The 1/12/25 Accident & Incident Report and Investigation indicated Resident 7 had a fall from his wheelchair at the nurse's station on 1/12/25 at 6:51 p.m. He attempted to stand up. A CNA (Certified Nurse Aide) ran to try and catch him but was unable to reach him in time. He fell , striking his head on a bedside table. […]

• No harm, potential for more than minimal, patternF740Feb 27, 2025

  Based on interview and record review, the facility failed to monitor and document target behaviors for 5 of 5 residents reviewed for unnecessary medications. (Residents C, G, 7, 9, and 36) Findings include: 1. The clinical record for Resident 7 was reviewed on 2/25/25 at 12:47 p.m. His diagnoses included, but were not limited to, depression and insomnia. The 1/29/25 care plan indicated he used an antidepressant medication related to depression. An intervention was to administer the medication as ordered by the physician and monitor/document side effects and effectiveness every shift. […]

• No harm, potential for more than minimal, patternF758Feb 27, 2025

  Based on interview and record review, the facility failed to monitor for side effects of psychotropic medications, as ordered, for 5 of 5 residents reviewed for unnecessary medications. (Residents C, G, 7, 9, and 36) Findings include: 1. The clinical record for Resident 7 was reviewed on 2/25/25 at 12:47 p.m. His diagnoses included, but were not limited to, depression. The 1/29/25 care plan indicated he used an antidepressant medication related to depression. An intervention was to administer the medication as ordered by the physician and monitor/document side effects and effectiveness every shift. The physician's orders indicated to administer one 50 milligrams (mg) tablet of sertraline daily, starting 1/9/25, for depression. […]

• No harm, potential for more than minimal, patternF804Feb 27, 2025

  Based on interviews, observations, and record reviews, the facility failed to provide a diet that was palatable and attractive to 9 of 9 residents reviewed. (Residents G, H, J, 1, 14, 30, 35, 36, and 37) Findings include: 1. The clinical record for Resident 36 was reviewed on 2/26/2025 at 11:30 a.m. The medical diagnoses included Parkinson's disease. A Quarterly Minimum Data Set (MDS) assessment, dated 11/27/2024, indicated Resident 36 was cognitively intact and had no significant weight changes. A physician order, dated 12/30/2024, indicated Resident 36 received a regular diet. During an interview on 2/25/2025 at 12:35 p.m., Resident 36 indicated the food was terrible. […]