Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Transcendent Healthcare Of Boonville - North during CMS and state inspections, most recent first.
Failure to Test and Track Flu-Like Illnesses: The facility did not maintain an effective IPC process for residents with cough, fever, wheezing, weakness, and other URI symptoms. Records showed orders for cough meds, O2, antibiotics, nebulizers, and CXR/COVID testing, but no documented influenza testing or IP notification/tracking for several residents. Two residents later tested positive for influenza A in the hospital and died, and another resident died in the facility before transfer.
A resident with dementia and severe cognitive impairment had a long history of falls, including 44 falls over about one year, and was care planned for multiple fall-prevention interventions such as non-slip socks, shower strips, fluorescent tape, Dycem, and furniture pads. After an unwitnessed fall, the resident was found face down with major head trauma, was bare foot without non-slip socks, and was later found to have a brain bleed. Surveyors observed that several listed interventions were not present in the room, and the DON and MDS Coordinator acknowledged that the care plan contained interventions that were no longer in use or had not been updated.
The facility failed to ensure the Food Service Director met required qualifications. The Dietary Manager reported she was still enrolled in the dietary manager course after previously missing the test by 1 point, and she later produced an invoice showing recent registration for the class. The Administrator stated the dietary manager should be certified, and the job description required state registration and completion of an accredited dietetic training course.
QAA/QAPI meetings did not consistently include the required members. Attendance records showed the Infection Preventionist, DON, and Medical Director were absent from multiple monthly meetings, and one QAPI meeting had no signed attendance. The Administrator stated the committee met monthly, and the QAPI plan said meeting minutes would reflect membership and attendance.
The facility failed to ensure a designated Infection Preventionist was onsite to carry out infection prevention and control activities. The Administrator stated the IP worked from another building, and the IP said she only came to the facility monthly for QAPI meetings and infection control in-services. The job description included rounding on nursing units, reviewing sanitation, supervising isolation precautions, and working throughout the facility, while the facility policy stated the IP is employed on site and at least part time.
Medication Storage and Labeling Deficiencies: Surveyors found unsecured and improperly labeled medications on two med carts and in the medication room refrigerator. An unopened Lantus pen and an open Lispro pen lacked open dates and expiration dates, a loose pill was found in a med cart, and two open bottles of tuberculin testing solution in the refrigerator were not dated. Staff interviews confirmed insulin should be refrigerated if unopened and opened vials should be dated.
A sink in the therapy restroom was observed loose and pulled away from the wall, and multiple personal care items in 4 shared restrooms were found without resident names. A CNA stated that unlabeled items were usually thrown away, and the DON/Administrator confirmed that the sink should be against the wall and resident belongings should be labeled.
A facility failed to develop care plans for a resident receiving antibiotics for UTI and another resident using oxygen. One resident had Parkinson's disease, dementia, and Alzheimer's disease and was ordered Cipro for UTI, but the record lacked a care plan for antibiotic use. Another resident with CHF was cognitively intact, required maximal assistance for several ADLs, and had oxygen orders, but the record lacked a care plan related to oxygen use. The MDS Coordinator stated care plans were initiated with MDS reviews and quarterly and needed updates when conditions changed.
A resident with Alzheimer's disease, a personality disorder, and a history of falls had a care plan that included fall-related interventions, including non-skid strips by the bed. After multiple unwitnessed falls with facial injuries, the resident was later observed without the non-skid strips in place on either side of the bed, and a CNA confirmed they were not present.
Failure to document rationale for declined GDR recommendations. A pharmacist recommended dose reductions for psychotropic and anticonvulsant meds for three residents with diagnoses including dementia, depression, anxiety, psychotic disorder, and CVA-related hemiplegia. The NP declined the recommendations but did not document a clinical reason for disagreement, despite facility policy requiring the prescriber to document the rationale when continuing psychotropic meds.
The facility failed to ensure influenza vaccines matched documented informed consent for two residents. One resident with dementia had records showing the POA declined the vaccine, yet the vaccine was still administered, and the POA later stated she never consented. Another resident had consent documented to receive the vaccine, but the record initially showed it was not given because it was declined, while a later immunization list showed the vaccine had in fact been administered.
A resident with early onset Alzheimer's, anxiety, and COPD, assessed as at risk for elopement, exited the facility unsupervised by using a keypad code on an exterior door. The resident was not discovered missing until a shift change, and was later found by law enforcement near a previous residence. The facility failed to provide adequate supervision and did not implement effective interventions to prevent the elopement.
A resident with an indwelling Foley catheter did not receive catheter care and monitoring as ordered by the physician, including missed catheter changes, saline flushes, and output documentation. Staff interviews revealed uncertainty about the resident's catheter care orders, and facility policy requirements for catheter care and documentation were not consistently followed.
The facility did not ensure that an RN was present for at least eight hours on two separate days, as required by policy. On those days, RN coverage was limited to less than eight hours, and the DON was not present in the building, though on call. This resulted in noncompliance with the facility's staffing requirements.
A resident with chronic conditions developed a stage III pressure ulcer on the coccyx due to the facility's failure to document and provide timely treatment. Despite being at risk and on a repositioning program, the resident's care plan was not updated promptly, and interventions were inconsistently documented. The ulcer worsened and became colonized with MRSA, highlighting a gap in the facility's pressure ulcer management.
The facility failed to maintain proper temperature controls for medications in the storage room. The refrigerator's temperature log had not been updated since May, and the freezer was covered in ice. Medications, including insulin pens, were stored at 46°F, outside the acceptable range of 33-41°F. The DON was unaware of the lapse in daily temperature checks, contrary to the facility's policy.
The facility failed to maintain infection control standards, as observed during a medication pass and review of Enhanced Barrier Precautions (EBP) for residents with indwelling devices and open wounds. A QMA administered a pill dropped on a cart with bare hands, violating protocols. Residents with MRSA, surgical incisions, and catheters lacked EBP signage and PPE. Staff interviews revealed a lack of awareness and training on EBP, contributing to these deficiencies.
A resident admitted on hospice care was found to lack physician orders for hospice and oxygen, despite being observed using oxygen and having a complex medical history. The resident's care plan noted hospice care needs and symptoms like restlessness and agitation. The MDS Coordinator confirmed the need for these orders, which were not documented, contrary to facility policy.
A facility failed to complete a comprehensive assessment within 14 days for a resident admitted with dementia, aphasia, depression, and gastrostomy status. The admission MDS assessment was still in progress past the required timeframe. The MDS Coordinator acknowledged the two-week completion requirement, and the facility's policy outlined the responsibility for timely submission to CMS.
The facility failed to develop specific care plans for two residents, one with significant weight loss and another dependent on staff for ADLs. Despite assessments indicating high nutritional risk and substantial assistance needs, the care plans were not updated to address these issues, as confirmed by the MDS nurse.
A resident was diagnosed with schizophrenia without proper diagnostic evaluation, despite being cognitively intact and showing no symptoms. The diagnosis was made by a former NP and physician, leading to the prescription of Latuda. The ADON acknowledged the inappropriate diagnosis and indicated it would be addressed.
A resident experienced significant weight loss without a prescribed regimen, and the facility failed to document a review or create a care plan following a high-risk nutritional assessment. Despite weight monitoring and dietary orders, the resident's care plan was not updated, and the RD did not document the weight loss review. The resident's medical history included bipolar disorder, anxiety, and major depression, and she often disposed of food despite encouragement to eat.
The facility failed to ensure CNAs were certified within 120 days of hire. Three CNAs were found not certified within the required timeframe. One CNA worked in dietary before starting as a CNA without certification, another was not certified, and a third was certified in another state but not locally. The DON confirmed the 120-day certification requirement, and the MDS Coordinator noted the absence of a specific policy, relying on state guidelines.
The facility did not ensure RN coverage for at least 8 hours a day on three weekends, as required by policy. The nursing schedule lacked RN coverage on specific dates, and the Administrator confirmed the deficiency.
Failure to Test and Track Flu-Like Illnesses
Penalty
Summary
The facility failed to establish a facility-wide infection prevention and control system to prevent, identify, report, investigate, and control infections for four residents who later required hospitalization or died. The report states that residents with upper respiratory symptoms were not tested or treated for influenza, and the facility did not investigate the cause of or track residents’ signs and symptoms. The deficiency involved residents with significant medical histories including dementia, COPD, chronic cough, dysphagia, acute respiratory failure with hypoxia, and severe cognitive impairment. One resident with dementia, acute kidney failure, and no documented respiratory infection developed cough, groaning, agitation, diminished lungs, and copious mucus drainage. Although chest x-rays, cough suppressants, oxygen, azithromycin, and nebulizer treatments were ordered, the record lacked documentation that influenza testing was done after upper respiratory symptoms were identified or that the Infection Preventionist was notified and tracking the symptoms. The resident was sent to the hospital with respiratory distress and increased shortness of breath, tested positive for influenza A on arrival, and later expired in the hospital with influenza A listed as the presumptive cause of death. A second resident with COPD and acute respiratory failure with hypoxia developed increased productive cough, wheezing, diminished lung sounds, weakness, lethargy, decreased appetite, and worsening vital signs. The record showed a COVID swab order, chest x-ray findings that could represent viral pneumonitis or atypical pneumonia, antibiotics, oxygen, and nebulizer treatments, but lacked documentation that influenza testing was performed or that the Infection Preventionist was notified and tracking the illness. The resident deteriorated, was ordered to be sent to the ER, and died in the facility before transfer. A third resident with COPD and chronic cough developed upper respiratory symptoms, fever, coarse and congested cough, wet lungs, and unresponsiveness. The record showed cough medications, ipratropium-albuterol, and Levaquin were ordered, but there was no documentation that the resident was tested for influenza after symptoms began or that the Infection Preventionist was notified and tracking the illness. The resident arrived at the hospital with severe sepsis, influenza A, possible bilateral pneumonia, metabolic encephalopathy, acute hypoxic respiratory failure requiring mechanical ventilation, and severe sinusitis, and later expired in the hospital. A fourth resident with dysphagia and no documented respiratory infection had fever, cough, and not feeling well, with acetaminophen and a COVID swab ordered, but the record lacked documentation of influenza testing, symptom tracking, or Infection Preventionist notification before the resident was transferred for PEG tube-related evaluation.
Fall Prevention Measures Not In Place for Resident With Frequent Falls
Penalty
Summary
The facility failed to ensure fall prevention measures were in place for a resident with dementia and severe cognitive impairment who was identified as being at risk for falls. The resident’s care plan included multiple fall-related interventions over time, including non-skid strips in the shower, fluorescent tape on a chair armrest, Dycem in a recliner, a spill-proof cup, and non-slip furniture pads. The resident’s record also showed 44 falls between January 2025 and January 2026, with prior fall documentation noting interventions such as non-slide socks at bedtime and reminders to use the call light and ask for assistance. On 1/5/26, the resident had an unwitnessed fall and was found face down in a puddle of blood in the bedroom with lacerations to the right forehead and temple, a skin tear to the right hand and knuckle, and abrasions to both knees and toes. The resident was bare foot and did not have non-slip socks on at the time of the fall. Staff had assisted the resident to the bathroom minutes earlier and had checked on the resident shortly before the fall. The resident became less responsive while waiting for the ambulance and was sent to the ER, where a hospital note documented hemorrhaging of the right frontal lobe and a laceration to the right forehead closed by sutures. Survey observations and interviews showed the fall-related interventions listed in the care plan were not consistently in place or were no longer applicable. The resident’s room did not have a recliner, drink cup, non-slip furniture pads, or fluorescent tape on a chair armrest, and the DON confirmed the resident did not have a recliner in the room and there were no non-slip pads under furniture. The DON also confirmed the shower room did not have non-slip strips, and stated that if the care plan said the resident should be wearing non-slip socks, the resident should have them on. The MDS Coordinator stated she left interventions in the care plan even if they were not working or no longer in use, and did not update the care plan with hospice interventions.
Food Service Director Qualification Deficiency
Penalty
Summary
The facility failed to ensure the kitchen manager met the required qualifications for the Food Services Director role. During interview, the Dietary Manager stated she was currently enrolled in the dietary manager course and reported that she had missed passing the test by 1 point in 2024 and had to wait to re-enroll. She later produced an invoice showing she had just registered for the class. The employee record showed the Food Service Manager started in the role on 1/2/26. The Administrator stated that the dietary manager should be certified during the survey period. The facility’s job description for the Director of Food Services stated the position must be registered as a Food Service Director in the state and be a graduate of an accredited dietetic training course approved by the American Dietetic Association.
QAA/QAPI Meetings Lacked Required Member Attendance
Penalty
Summary
The facility failed to ensure the required staff were present at the monthly Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings. Record review showed that the Infection Preventionist and Director of Nursing were not present at the 2/20/25, 3/19/25, and 4/22/25 meetings, and the Infection Preventionist and Medical Director were not present at the 7/28/25 and 10/16/25 meetings. The Infection Preventionist was also not present at the 1/12/26 and 1/16/26 meetings. During interviews, the Administrator stated the QAA/QAPI committee met monthly and provided attendance sheets for the meetings. The Infection Preventionist stated she worked from another building and came to the facility monthly for QAPI meetings and infection control in-services. The Administrator also stated there was a QAPI meeting on 2/6/26, but no attendance was signed during the meeting. The 2026 QAPI Plan stated that the Executive Leadership team would assure time and resources were provided to designated persons participating on the QAPI Steering Committee or associated work groups, and that meeting minutes would reflect membership and attendance and be reported quarterly in the monthly QAPI summary report.
Infection Preventionist Not Onsite
Penalty
Summary
The facility failed to ensure a designated infection preventionist was onsite to implement programs and activities to prevent and control infections. During the entrance conference, the Administrator stated that the facility's Infection Preventionist worked from another building. Review of the Infection Control Nurse job description showed duties that included making rounds to nursing units for case findings, reviewing environmental sanitation procedures, supervising isolation precautions and practices, visiting isolated residents as necessary to ensure isolation precautions and aseptic technique were followed, and working in office areas as well as throughout the facility. During interview, the Infection Preventionist stated she worked from another building and came to the facility monthly for QAPI meetings and staff in-services related to infection control. The facility's undated Infection Preventionist policy stated that the infection preventionist is employed on site and at least part time.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly secured and labeled in accordance with accepted professional principles. During observation of the West Medication Cart, surveyors found one unopened Lantus pen for Resident 26 with no open date or expiration date and one open Lispro insulin pen for Resident 4 with no open date or expiration date. During observation of the East Medication Cart, surveyors found one large round white pill marked N32. QMA 4 stated that unopened insulin should be refrigerated, and QMA 5 stated that loose pills should not be left in the medication carts and should be placed in a drug buster solution and reported to the nurse. Surveyors also observed the [Pharmacy Name] Medication Room refrigerator and found two open bottles of tuberculin testing solution with no open date or expiration date. LPN 6 stated the vials should be dated when opened. The DON stated that insulin needs to go straight to the refrigerator if not used immediately and needs to be dated with the open date. The facility provided a current undated Medication Labelling and Storage policy stating that medications and biologicals are stored in their original packaging, refrigerated medications are stored in a secured refrigerator, and multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies otherwise.
Unsafe Sink and Unlabeled Personal Items in Shared Restrooms
Penalty
Summary
The facility failed to ensure that a sink in the therapy restroom was safely secured to the wall and failed to ensure that personal belongings in 4 of 4 shared restrooms were labeled with resident names. During random observations of the shared restrooms between multiple room pairs, surveyors found multiple personal care items without names, including shampoo, toothpaste, lotion, a toothbrush, mouthwash, shaving cream, a tooth cup, and combs. The Administrator later stated that the sink should be against the wall and that all residents' personal belongings should be labeled with their names. In the therapy restroom, the sink was observed to have pulled away from the wall and was loose in movement. During interview, a CNA stated that she knew what most residents were capable of doing for hygiene, but that all residents' personal items needed to be labeled with their names and that if items were not labeled, she would usually throw them away. The facility's policy on a homelike environment indicated that staff and management maximize characteristics of a clean, sanitary, and orderly environment, and the personal property policy stated that resident belongings are treated with respect and that personal care items are properly stored in individual containers.
Missing Care Plans for Antibiotic and Oxygen Use
Penalty
Summary
The facility failed to develop care plans for 1 of 1 residents reviewed for UTI and 1 of 1 residents reviewed for respiratory care. Resident 3 had diagnoses including Parkinson's disease without dyskinesia, unspecified dementia, and Alzheimer's disease. The current quarterly MDS assessment dated 12/15/25 indicated the resident was mildly cognitively intact and needed supervision to eat, with partial to moderate assistance required for toileting, dressing, hygiene, and transferring. Current physician orders included Cipro 500 mg BID for 7 days for UTI, dated 2/7/26, but the clinical record lacked a care plan for antibiotic use during the period the resident was receiving the medication. Resident 34 was admitted with diagnoses including congestive heart failure. The most recent annual MDS assessment dated 1/3/26 indicated the resident was cognitively intact, required maximal assistance for toileting, bathing, and transfers, and was using oxygen therapy. Physician orders included oxygen via nasal cannula at 2 liters two times a day, starting 2/8/26, and changing all oxygen supplies every Sunday on night shift, starting 2/1/26. The clinical record lacked a care plan related to oxygen use. The MDS Coordinator stated care plans were initiated with MDS reviews and quarterly, and that care plans needed to be updated with new interventions with changes and needs.
Failure to Implement Fall Intervention for Resident with Repeated Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was developed and implemented with interventions for a resident with a history of falls. Resident 21 had diagnoses including Alzheimer's disease, personality disorder, and a nasal bone fracture, and the quarterly MDS indicated the resident was cognitively intact and required assistance with dressing, mobility, and hygiene, with a history of falls. The care plan identified a potential for fall-related injury related to decreased mobility, and included interventions such as sending the resident to the ER, reviewing medications for possible adverse drug reactions contributing to falls, and placing non-skid strips on the exit side of the bed floor. After an unwitnessed fall on 11/22/25, the resident was found ambulating in the hallway with blood running down the face and stated, "I fell out of bed." The resident sustained facial injuries including a forehead laceration, nasal bridge deformity with swelling, redness, and abrasion, and the post-hospital summary documented a nasal fracture, left maxillary fracture, and a facial laceration sealed with wound glue. A second unwitnessed fall occurred on 11/23/25, with the resident found sitting on the floor with blood running down the face and a hematoma above the left orbital area. An IDT note on 11/24/25 added the intervention for non-skid strips by the bed, but during observations on 2/12/26 and 2/13/26, no non-skid strips were seen on either side of the bed. A CNA stated the resident should have non-skid strips on the sides of the bed and did not.
Failure to Document Rationale for Declined GDR Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented a clinical contraindication when gradual dose reduction (GDR) was declined for three residents reviewed for unnecessary medications. For Resident 2, who was admitted with dementia and was moderately cognitively impaired, the record showed orders for duloxetine and clonazepam, and the quarterly MDS indicated use of antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. A Pharmacy Physician Recommendations form dated 9/2/25 showed the pharmacist recommended reducing duloxetine and clonazepam, but the Nurse Practitioner did not provide a rationale for declining the recommendations. For Resident 4, who had major depressive disorder, anxiety disorder, and hemiplegia/hemiparesis following cerebrovascular disease, the record showed orders for trazodone and desvenlafaxine, and the MDS indicated the resident was cognitively intact and required varying levels of assistance with care. Consultant Pharmacist recommendations dated 12/18/25 for divalproex and 1/21/26 for trazodone were reviewed, and the Nurse Practitioner did not provide a rationale for disagreement with the dose reduction recommendations. For Resident 33, who had brief psychotic disorder, anxiety disorder, and unspecified dementia and was severely cognitively impaired, the record showed orders for divalproex and buspirone. Consultant Pharmacist recommendations dated 12/18/25 for buspirone and 1/21/26 for divalproex were reviewed, and the Nurse Practitioner did not provide a rationale for disagreement with the drug dose reduction recommendations. During interview, the Nurse Practitioner stated that if there is a disagreement on the GDR there needs to be a reason why there is disagreement. The facility policy on Psychotropic Medication Use stated that if psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication should be continued and document the rationale for this decision.
Influenza Vaccination Given or Withheld Contrary to Documented Consent
Penalty
Summary
The facility failed to ensure influenza vaccinations were provided according to residents’ informed consent for 2 of 6 residents reviewed for immunizations. One resident with dementia had documentation in the record showing the influenza vaccine was declined by the POA, yet the clinical record also showed the resident received the influenza vaccine in the left deltoid. The record lacked documentation identifying who gave consent for the vaccination, and the POA later stated she did not consent to the vaccine and would have declined it if asked before it was administered. Another resident with dysphagia and influenza A had an informed consent form signed by the responsible party indicating consent to receive the influenza vaccine, but the clinical record lacked documentation that the vaccine was given. The MDS indicated the resident did not receive the influenza vaccination because she declined it, yet the facility’s immunization list later showed the resident received the influenza vaccine. The Infection Preventionist stated that influenza vaccine consents were obtained on admission and annually, and that for residents with cognitive impairment, the POA or guardian gave consent or declined on the resident’s behalf.
Failure to Prevent Elopement of At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a history of exit-seeking and elopement risk was able to leave the facility unsupervised. The resident, diagnosed with early onset Alzheimer's disease, anxiety, depression, and COPD, had recently been admitted and was assessed as at risk for elopement based on prior behaviors and assessment scores. Despite this, the resident was able to exit the building through a keypad-controlled door by entering the correct code, which was accessible due to a label indicating the code format. The resident left the facility at approximately 5:30 A.M. and was not discovered missing until 7:15 A.M. during a shift change, resulting in a significant delay before a search was initiated and law enforcement was notified. The resident's care plan included monitoring for sleep issues and mood, but there was no evidence of specific interventions to address the elopement risk beyond routine checks. Staff observations and documentation indicated the resident had been awake and in her room earlier in the morning, but there was no continuous supervision or targeted monitoring for exit-seeking behavior. The facility's policies required routine checks every two hours, but the resident was able to leave undetected between checks, and the absence of an alarm or notification system on the exit door further contributed to the failure to prevent the elopement. Interviews with staff and the resident's Power of Attorney revealed that the resident had memory issues and a desire to return to a previous home, which was a known risk factor. The resident was found by law enforcement approximately 1.2 miles from the facility, near a former residence, after being missing for several hours. The incident demonstrated a lack of adequate supervision and failure to implement effective interventions for a resident assessed as at risk for elopement, resulting in the resident's unsupervised departure from the facility.
Removal Plan
- Completed audits of clinical records for residents at risk for exit-seeking behavior or elopement.
- Removed labels indicating keycodes from keypads.
- Provided in-service training to staff on the elopement exit seeking policy and establishing interventions for residents assessed to be at risk for wandering/elopement.
Failure to Implement and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to implement and document physician-ordered catheter care and related interventions for a resident with an indwelling Foley catheter. The resident, who had diagnoses including neuromuscular dysfunction of the bladder, prostatic hyperplasia with lower urinary tract symptoms, and dementia, was observed with a catheter drainage bag attached to their wheelchair. Review of the resident's medical record revealed multiple physician orders for catheter care, including daily catheter changes, regular saline flushes, and monitoring of catheter output each shift. The resident's care plan also required catheter care as ordered, intake and output monitoring, and emptying the catheter bag at least three times daily. Documentation on the Treatment Administration Record (TAR) showed that several catheter care orders were not completed or documented on multiple occasions, including missed catheter changes, saline flushes, and output monitoring on specified dates. Interviews with facility staff indicated uncertainty and lack of awareness regarding the resident's catheter care orders and the required documentation. Facility policy required observation and documentation of urine output and adherence to catheter care procedures, but these were not consistently followed for the resident.
Failure to Provide Required RN Coverage for Eight Hours Daily
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight hours daily as required. Review of the nursing schedule showed that on two specific days, RN coverage did not meet the eight-hour minimum: on one day, an RN was scheduled from midnight to 7:00 A.M., and on another day, from 6:30 P.M. to midnight, resulting in less than eight hours of RN presence each day. An LPN who worked those weekends confirmed that the Director of Nursing (DON) was not present in the building during those shifts, although the DON was on call. Facility policy requires an RN to provide services for at least eight consecutive hours every 24 hours, seven days a week, which was not met on these occasions.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer in a resident who initially had no pressure-related skin impairment. Resident 12, who had chronic kidney disease, vitamin deficiency, atrial fibrillation, and chronic obstructive pulmonary disease, developed a stage III pressure ulcer on the coccyx while in the facility. The resident was at risk for pressure injuries as indicated by a Braden scale assessment and was on a turning and repositioning program. However, after the ulcer developed, there was no initial assessment documented, and no treatment was provided for four days. The care plan was not updated promptly to reflect the new condition, and interventions were not consistently documented as completed. The resident's care plan included interventions for potential skin breakdown due to decreased mobility and incontinence, but these were not effectively implemented. The resident experienced a decline in abilities, increased incontinence, and was occasionally incontinent of bladder and frequently incontinent of bowel. Despite these risk factors, the facility did not document any wound treatment or assessment until several days after the ulcer was first noted. The resident's wound was eventually assessed and treated, but the delay in care contributed to the development and worsening of the ulcer. Observations and interviews revealed that the resident was on a pressure-reducing air mattress and had a history of loose stools, which increased the risk of skin breakdown. The facility's failure to document and address the pressure ulcer promptly resulted in the wound becoming colonized with MRSA. The Assistant Director of Nursing could not explain the lack of documentation and treatment during the initial days of the ulcer's development, highlighting a gap in the facility's response to pressure ulcer prevention and management.
Improper Medication Storage Temperature Control
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored under proper temperature controls in the medication storage room. During an observation on November 13, 2024, it was noted that the refrigerator's temperature log had not been updated since May 28, 2024, and the freezer area was covered in ice. Medications, including insulin pens, were stored in this refrigerator. The Director of Nursing (DON) indicated that nursing staff should check and document the refrigerator temperature daily, but she was unaware of why this was not being done. At the time of observation, the refrigerator temperature was 46 degrees Fahrenheit, which was outside the acceptable range of 33-41 degrees Fahrenheit as indicated on the log sheet. A current Medication Labeling and Storage Policy provided by the MDS Coordinator stated that medications requiring refrigeration should be stored in a refrigerator located in the medication room at the nurse's station.
Infection Control Deficiencies in Medication Handling and EBP Implementation
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, as observed during a medication pass and review of Enhanced Barrier Precautions (EBP) for several residents. One incident involved a Qualified Medication Aide (QMA) who dropped a pill on the medication cart, picked it up with a bare hand, and administered it to a resident. This action violated infection control protocols, which require medications to be discarded if contaminated and not to be touched with bare hands. Additionally, the facility did not implement EBP for residents with indwelling devices and open wounds. Resident 12, who had a wound positive for MRSA, initially lacked signage and PPE indicating EBP. Similarly, Resident 44, with a surgical incision and a PICC line, and Resident 205, with a gastrostomy tube, were not placed on EBP, and there was no signage or PPE available. Resident 2, with an indwelling urinary catheter and a pressure ulcer, also lacked EBP orders and signage. Interviews with staff revealed a lack of awareness and training regarding EBP. The Infection Preventionist admitted that the facility was unaware of the need for EBP for residents with open wounds and indwelling devices. The facility's policies on administering medications and EBP were not effectively communicated or implemented, leading to these deficiencies in infection prevention and control.
Lack of Physician Orders for Hospice and Oxygen
Penalty
Summary
The facility failed to obtain physician orders for a resident's immediate care upon admission, specifically lacking orders for hospice and oxygen. This deficiency was identified for a resident who was admitted on hospice care and was observed using oxygen at 2 liters per minute via nasal cannula. Despite the resident's complex medical history, including liver cell carcinoma, chronic obstructive pulmonary disease, and hypertension, the necessary physician orders for hospice care and oxygen were not documented in the resident's clinical records. The resident's care plan indicated they were on hospice care and experiencing symptoms such as restlessness, agitation, and chronic confusion, requiring 1:1 supervision and frequent cues. The resident also had ongoing pain, which contributed to their agitation and restlessness. During an interview, the MDS Coordinator confirmed that the resident should have had physician orders for hospice and oxygen. The facility's policy stated that orders for a resident's immediate care should be provided by a physician upon admission, highlighting the oversight in this case.
Failure to Complete Timely Comprehensive Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days of admission for one of the five residents reviewed who were admitted in the last 30 days. Resident 205, who was admitted with diagnoses including unspecified dementia, aphasia, depression, and gastrostomy status, did not have their admission MDS assessment completed within the required timeframe. The assessment, dated 10/24/24, was still in progress and should have been completed by 11/7/24. During an interview, the MDS Coordinator acknowledged the two-week timeframe for completing the admission MDS assessment. The facility's policy, provided by the MDS Coordinator, outlined the responsibility for ensuring timely submission of assessments to CMS' QIES ASAP system according to federal and state guidelines.
Failure to Develop Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop a resident-specific care plan for two residents, leading to deficiencies in addressing their needs. Resident 25, diagnosed with bipolar disorder, anxiety, and major depression, experienced a significant weight loss of over 10% from March 7 to March 27, 2024. Despite a nutritional assessment indicating high risk and the significant weight loss, the care plan was not updated to address these nutritional concerns. The existing care plan only noted a potential for nutritional problems without any specific interventions following the assessment or weight loss. Resident 44, observed to be a bilateral lower leg amputee, required substantial assistance for activities of daily living (ADLs) such as toileting, bathing, and transfers. The care plan for this resident included interventions related to the amputations but failed to address the resident's dependency on staff for completing ADLs. The MDS nurse confirmed that care plans should have been developed to address these specific needs, as per the facility's policy on comprehensive, person-centered care plans.
Inappropriate Schizophrenia Diagnosis Without Proper Evaluation
Penalty
Summary
The facility failed to ensure that a new diagnosis of schizophrenia for a resident followed the professionally accepted diagnostic process. The resident, who was over the age of 65 and cognitively intact, was diagnosed with schizophrenia without documented screening, testing, or symptoms. The resident's medical history included bipolar disorder, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. Despite the absence of behaviors, hallucinations, or delusions, the resident was prescribed Latuda for schizophrenia. During an observation and interview, the resident appeared alert, oriented, and well-groomed, answering questions appropriately. A review of the resident's records showed that the schizophrenia diagnosis was added in December of the previous year, and the medication Latuda was started in September of the same year. However, there was no diagnostic examination or evidence supporting the schizophrenia diagnosis in the resident's records. The Assistant Director of Nursing (ADON) indicated that the diagnosis was inappropriately given by a nurse practitioner and physician who were no longer affiliated with the facility. The ADON acknowledged that the facility attempted to inform the practitioners that a new diagnosis of schizophrenia requires meeting specific diagnostic criteria, but the diagnosis was still added. The ADON believed the diagnosis had been removed and indicated it would be addressed.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure adequate nutrition for a resident who experienced significant weight loss. The registered dietitian did not document a review of the resident's weight loss, nor was a care plan created following a nutritional assessment that indicated the resident was at high risk. The resident, who was not on a prescribed weight loss regimen, reported losing weight and was observed sitting on the edge of her bed. Her medical history included bipolar disorder, anxiety, and major depression. The resident's weight records from March to July showed a significant decrease from 170.9 lbs to 126.6 lbs. Despite this, no new nutritional care plans were developed after a significant weight loss was noted on March 27. The resident's physician orders included a regular diet and weekly weight monitoring, but the house supplement for weight loss was discontinued. The resident's care plan only noted a potential for nutritional problems without further updates following the assessment or weight loss. Nurse's progress notes indicated the resident's lack of desire to eat, weakness, and confusion. The resident was treated for Helicobacter pylori and had a BMI of 23.9. Despite attempts to encourage eating and offering supplements, the resident often disposed of food. Interviews with the MDS nurse and ADON revealed that the RD forgot to document the weight loss review, although the facility was addressing the issue through medication adjustments and supplements. The facility's policy required immediate notification of the dietitian for significant weight changes, but this was not followed effectively.
Failure to Ensure CNA Certification Within 120 Days
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) were certified within 120 days of their hire date, as required. During a review of employee records, it was found that three CNAs were not certified within the stipulated time frame. One CNA, hired on April 14, 2023, worked in dietary until July 3, 2024, when she started working as a CNA but was not certified. Another CNA, hired on July 3, 2024, was also not certified. A third CNA, hired on October 5, 2023, was certified in Illinois but not in Indiana. The Director of Nursing confirmed that CNAs have 120 days after their hire date to become certified. Additionally, the Minimum Data Set Coordinator indicated that there was no specific policy on CNA certification, and the facility followed state guidelines.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for at least 8 hours a day, as required, on three out of five weekends reviewed. The nursing schedule, reviewed on September 3, 2024, for the period from August 2, 2024, to September 3, 2024, showed a lack of RN coverage for at least 8 hours on the dates of August 3, August 17, and August 31, 2024. During an interview on September 3, 2024, the Administrator acknowledged that the schedule did not meet the requirement for RN coverage. Additionally, the facility's current policy for departmental supervision in nursing mandates that an RN provides services for at least eight consecutive hours every 24 hours, seven days a week.
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What surveyors actually found near you
We read the 268 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Boonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transcendent Healthcare Of Boonville | 1.1 mi | ★★★★★ | 12 | 0 |
| Woodmont Health Campus | 3.6 mi | ★★★★★ | 9 | 0 |
| Cypress Grove Rehabilitation Center | 9 mi | ★★★★★ | 7 | 0 |
| Brickyard Healthcare - Woodlands Care Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Hamilton Pointe Health And Rehab | 11 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.