Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Boonespring Transitional Care Center, Llc during CMS and state inspections, most recent first.
The facility failed to maintain a clean and homelike environment, with strong urine odors detected on furniture in common areas. Inconsistent cleaning practices and lack of a regular cleaning schedule contributed to the issue.
The facility failed to sanitize a mechanical lift between resident use, as required by its infection control policy. Observations and staff interviews revealed inconsistent training and understanding regarding the disinfection of shared medical equipment, including Hoyer lifts. The Infection Preventionist and other staff confirmed that the lifts should be disinfected, but this was not consistently practiced.
The facility failed to develop and implement comprehensive care plans for five residents, leading to various deficiencies, including unaddressed respiratory events, dislodged feeding tubes, unmanaged trauma histories, and inadequate interventions for smoking behaviors.
A resident experienced a significant change in condition, including lethargy and low oxygen saturation, which was not properly assessed or documented by the nursing staff. The resident was later found in a critical state and transported to the Emergency Department, revealing a failure to follow facility policies and procedures.
A facility failed to provide trauma-informed care for a resident with a history of childhood sexual abuse. The resident's trauma history was not documented or communicated to staff, leading to inadequate care and increased agitation during incontinence care.
A resident alleged that an aide was too rough and pushed his/her head down, but the staff member present failed to report the incident to the administration. The facility's policy required immediate reporting, but the allegation was only reported the following day. Interviews revealed a lack of awareness and communication among staff members regarding the incident.
A resident's gastric tube was dislodged during incontinence care due to insufficient caution by an STNA, requiring emergency replacement. The facility's policy lacked instructions on preventing dislodgement, and the resident's care plan did not specify measures for prevention. The DON provided additional education to the involved STNA but did not extend this to all aides.
The facility failed to ensure competent nursing staff for a resident with a feeding tube. Interviews revealed that STNAs were not trained on the necessary precautions, and the facility's training modules did not include specific courses on the care of residents with indwelling devices. Both LPNs and RNs were unaware of any specific training provided to aides regarding feeding tube precautions, and the DON confirmed that education was not consistently given to all staff.
The facility failed to ensure medications were not expired, specifically for a resident's Fluticasone nasal spray, which was used beyond the manufacturer's recommended number of sprays. Staff interviews revealed a lack of adherence to the manufacturer's guidelines for medication expiration.
The facility failed to ensure a safe environment by allowing residents to smoke on the campus, contrary to its non-smoking policy. Residents with respiratory conditions and cognitive impairments were observed smoking, sometimes with staff assistance. The facility's care plans did not adequately address smoking behaviors, and staff were not properly informed or trained to enforce the policy.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for thirty-seven of forty-eight sampled residents. Observations revealed a strong urine odor on two sofas in the 1200 Unit and one armchair in the 1400 Unit. A resident was observed sitting in an armchair with a wet spot on their pants, and the armchair smelled of urine. The State Survey Agency (SSA) Surveyor also noted a strong urine odor on the sofas in the 1200 Unit, which required the surveyor to shower and change clothes after exposure. Interviews with the Environmental Services Floor Staff (EVS) and the Environmental Services Director (ESD) revealed inconsistencies in the cleaning process for common area furniture. The EVS could not find a schedule for steam cleaning the sofas, and the ESD stated that the upholstery cleaner was used as needed rather than on a regular schedule. The ESD also mentioned that if a bodily fluid was on furniture, nursing staff would handle it first. The Administrator, who had been in the position since November 2023, stated that her expectation was for all staff members to work together to meet the residents' needs.
Failure to Sanitize Mechanical Lifts Between Resident Use
Penalty
Summary
The facility failed to sanitize one of four mechanical lifts between resident use on the first floor. The facility's policy on Infection Control Transmission Based Precautions required that non-critical resident care equipment be adequately cleaned and disinfected before use for another resident. However, observations revealed that staff did not disinfect the Hoyer lift before using it with different residents. Interviews with various staff members, including nurse aides and the Infection Preventionist, indicated a lack of consistent training and understanding regarding the disinfection of shared medical equipment, including the Hoyer lifts. Some staff members believed that the lifts were cleaned only at night or when visibly soiled, while others were unsure if they needed to disinfect the lifts at all. The Infection Preventionist stated that staff received training on infection control and that audits were performed to ensure compliance, but no audits were provided upon request. The Director of Nursing and the Corporate Educator confirmed that the facility's policy required disinfection of medical equipment, including Hoyer lifts, but there was a discrepancy in the understanding and implementation of this policy among the staff. The Administrator expected all staff to follow the facility's policies, but the lack of proper disinfection of the Hoyer lifts between resident use indicated a failure in adhering to the infection control protocols.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for five residents, leading to various deficiencies. Resident #229 experienced an untoward respiratory event, was not wearing his/her oxygen, and the physician was not notified. Additionally, staff assisted the resident in smoking despite care plan interventions to refrain from smoking. This resulted in the resident being sent to the hospital. Interviews with staff and family confirmed these lapses in care and documentation. Resident #4 had a gastric feeding tube that was dislodged, but the care plan did not include interventions to prevent dislodgement. Staff interviews revealed inconsistent communication regarding the resident's needs and the absence of specific precautions in the care plan. This lack of detailed care planning contributed to the incident of the feeding tube falling out. Resident #106 had a history of childhood abuse and trauma, which was not addressed in the care plan. The resident became distressed during incontinence care, but no interventions were included to manage this distress. Interviews with staff and the resident's representative highlighted the lack of communication and documentation regarding the resident's trauma history. Similar deficiencies were noted for Resident #87 and Resident #105, where care plans did not address smoking behaviors adequately, leading to noncompliance and staff-assisted smoking activities.
Failure to Properly Assess and Document Change in Resident's Condition
Penalty
Summary
The facility failed to properly assess a resident, Resident #229, when there was a significant change in condition. On the night of 02/04/2024, a Kentucky Medication Aide (KMA) found Resident #229 lethargic and slurring words and reported this to Registered Nurse (RN) #2. However, RN #2 did not document the incident or contact the physician. The resident was later found with an oxygen saturation level of 60%, and the oxygen flow had been increased from 2.5 liters to 4 liters without proper documentation or physician notification. The following morning, RN #1 discovered the resident slumped over in bed and still lethargic. RN #1 called 911, and the resident was transported to the Emergency Department, where the resident was diagnosed with delirium, elevated troponin, and chronic obstructive pulmonary disease (COPD). The facility's Director of Nursing (DON) confirmed that the incident was not documented in the resident's electronic medical record (EMR) and that the physician was not notified as required by the facility's policies. Interviews with the facility's staff, including the Primary Care Physician (PCP) and the Administrator, revealed that the staff did not follow the facility's policies and procedures for documenting and reporting changes in the resident's condition. The DON emphasized that if an event is not documented, it is considered not to have happened. The Administrator stated that staff members are expected to follow the physician's orders and report any concerns to the nursing team.
Failure to Provide Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was a trauma survivor received trauma-informed care. Resident #106, who had a history of childhood sexual abuse, was not identified as a trauma survivor in the facility's assessments or care plans. The resident's son had informed some aides about the resident's history, but this information was not communicated effectively to all staff or documented in the care plan. As a result, the resident's agitation during incontinence care was not addressed with appropriate, trauma-informed interventions. The facility's policy required assessing each resident for a history of trauma and collaborating with the resident and their family to identify potential triggers and develop a resident-centered care plan. However, the facility's Social Service Assessment and History form did not include questions about trauma history, and there was no documentation of Resident #106's traumatic experiences. Interviews with staff, including a State tested Nurse Aide (STNA), a Registered Nurse (RN), the Social Services Director (SSD), the Unit Manager (UM), the Director of Nursing (DON), and the Administrator, revealed that they were unaware of the resident's trauma history and had not implemented specific interventions to mitigate triggers. The lack of documentation and communication about Resident #106's trauma history led to inadequate care. Staff members, including the STNA and RN, observed the resident's anxiety and agitation during incontinence care but did not have the necessary information or interventions to address these behaviors effectively. The facility's failure to identify and document the resident's trauma history resulted in a lack of trauma-informed care, potentially causing re-traumatization and distress for the resident.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse for one of its residents, who claimed that an unknown aide had been too rough and pushed his/her head down towards his/her chest. This incident was reported in the presence of a State Survey Agency (SSA) Surveyor and a State tested Nurse Aide (STNA) #7, who failed to notify the facility's administration of the allegation. The facility's policy required staff to report such allegations immediately to the Administrator, who was then to report them to the state agency within two hours. However, the allegation was not reported until the resident informed the Corporate Educator the following day, who then reported it immediately. The resident had a history of hemiplegia, chronic pain syndrome, and cervical disc degeneration, and was assessed as cognitively intact and dependent on staff for toileting. Interviews with various staff members revealed a lack of awareness and communication regarding the resident's allegation. The Social Services Director (SSD) had not been involved in the investigation despite her role in interviewing residents with a BIMS score of eight or above. The Director of Nursing (DON) and the Administrator both stated that they expected staff to report such allegations immediately, but were unaware that the resident had made an allegation in the presence of another staff member and an SSA Surveyor. The Corporate Educator reported the resident's allegation immediately upon being informed but noted discrepancies in the resident's account of the incident. The failure to report the allegation promptly and the lack of communication among staff members led to the deficiency identified in the report.
Failure to Prevent Dislodgement of Feeding Tube
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident receiving enteral feeding, leading to the dislodgement of the resident's gastric tube. The incident occurred when a State tested Nurse Aide (STNA) was changing the resident's brief and did not prevent the tube from becoming dislodged. The resident, who was cognitively intact and required a feeding tube due to dysphagia, had to be transferred to the emergency department for a new gastric tube placement. The facility's policy on medication administration via gastric/jejunostomy tubes did not include instructions on preventing tube dislodgement, and the resident's care plan lacked specific measures for preventing dislodgement. Interviews revealed that the STNA involved did not exercise sufficient caution during incontinence care, leading to the tube's dislodgement. The Registered Nurse (RN) on duty confirmed that the tube was in correct placement earlier in the shift and found it on the floor with the balloon anchoring device still inflated after the incident. The Director of Nursing (DON) acknowledged that the STNA was not careful enough and provided additional education to the STNA involved but did not extend this education to all aides facility-wide. The Administrator also expected aides to use caution but did not ensure that all aides were educated on the precautions necessary for handling feeding tubes.
Failure to Ensure Competent Nursing Staff for Feeding Tube Care
Penalty
Summary
The facility failed to ensure competent nursing staff for a resident with a feeding tube. Interviews with State Tested Nurse Aides (STNAs) revealed that they were not trained on the precautions needed when caring for residents with feeding tubes. The facility's training modules did not include specific courses on the care of residents with indwelling devices such as gastric tubes. One STNA mentioned that she had to rely on her own experience to ensure the feeding tube was not tangled, as she had not received formal training on this matter. Another STNA/Kentucky Medication Aide (KMA) confirmed the lack of training and stated that the facility did not conduct refresher training in the form of return demonstrations, only periodic online learning modules that did not cover feeding tubes. Further interviews with Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) indicated that they were unaware of any specific training provided to aides regarding feeding tube precautions. The Staff Recruitment and Retention Coordinator (SRRC) and the Assistant Director of Nursing (ADON) also confirmed that the orientation and ongoing training for nurse aides did not include specific considerations for feeding tubes. The Director of Nursing (DON) mentioned that while some education was provided to individual aides, it was not consistently given to all staff. The Administrator deferred detailed questions about training to the ADON and DON, indicating a lack of comprehensive training for nurse aides on feeding tube care.
Failure to Discard Expired Medication
Penalty
Summary
The facility failed to ensure medications used by residents were not expired, specifically for one of the eight sampled medication carts. The medication cart on the 1300 Unit contained a bottle of Fluticasone nasal spray prescribed for a resident, which had been used beyond the manufacturer's recommended number of sprays. The manufacturer's guidelines indicated that each bottle should provide 120 sprays and be discarded afterward, but the resident had received 210 sprays since the bottle was opened. The medication administration record confirmed the overuse, and the bottle was observed to have a substance on the nasal tip, indicating potential contamination. Interviews with staff, including a Kentucky Medication Aide, a Registered Nurse, the Director of Nursing, and the Pharmacist, revealed a lack of knowledge and adherence to the manufacturer's guidelines for medication expiration. The staff believed that medications expired based on the date on the box or after three months of opening, contrary to the manufacturer's instructions. The facility's medication storage policy required following the manufacturer's guidelines, but this was not implemented correctly. The Director of Nursing and the Pharmacist acknowledged that expired medications might not be effective and could pose a risk of infection to the resident.
Failure to Enforce Non-Smoking Policy
Penalty
Summary
The facility failed to ensure a safe and homelike environment by allowing residents to smoke on the facility's campus, contrary to its non-smoking policy. Resident #229, who was admitted for rehabilitation services and had a history of chronic obstructive pulmonary disease (COPD) and other respiratory conditions, was observed smoking outside the facility. Interviews with staff and family members confirmed that Resident #229 smoked regularly, sometimes with the assistance of staff, and even took his/her oxygen tank outside while smoking. The facility did not have a comprehensive care plan addressing the resident's smoking habits or interventions to prevent smoking, and staff were not adequately informed or trained to enforce the non-smoking policy. Resident #87, who had a history of nicotine dependence and was cognitively intact, was also found to be smoking on the facility's grounds. The resident had cigarettes and a lighter in his/her possession, and staff were reported to assist the resident in obtaining cigarettes and allowing smoking outside. The facility's care plan for Resident #87 did not include measures to address the resident's smoking behavior until after the surveyors' observations. The Social Service Director admitted to not following up with the resident timely to ensure compliance with the non-smoking policy. Resident #105, who had severe cognitive impairment and required substantial assistance with daily activities, was also observed smoking on the facility's grounds. Staff were reported to assist Resident #105 by lighting cigarettes and allowing smoking outside. The facility's care plan for Resident #105 included an intervention to encourage refraining from smoking, but it was not effectively implemented. Interviews with various staff members revealed a lack of awareness and enforcement of the non-smoking policy, with some staff believing that residents were allowed to smoke outside. The facility's administration acknowledged the non-smoking policy but failed to ensure its consistent enforcement and did not have the necessary supplies or assessments for safe smoking practices.
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Illustrative
What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Union
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belmont Terrace Nursing And Rehabilitation Center | 6.9 mi | ★★★★★ | 0 | 0 |
| Florence Park Care Center | 7.2 mi | ★★★★★ | 23 | 1 |
| Woodcrest Nursing And Rehabilitation Center | 7.8 mi | ★★★★★ | 0 | 0 |
| Waters Of Rising Sun, The | 7.8 mi | ★★★★★ | 20 | 0 |
| Emerald Trace | 7.8 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.