Inspection Reports for Transcendent Healthcare of Boonville
725 S SECOND ST, BOONVILLE, IN, 47601
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 25, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving resident care issues such as misappropriation, wound care, pharmaceutical services, supervision to prevent elopement, and medication administration, as well as environmental and safety concerns including Life Safety Code violations. Complaint investigations included substantiated findings related to resident supervision lapses, care plan inaccuracies, medication errors, and failure to report unusual occurrences, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints were either unsubstantiated or corrected upon follow-up visits. The facility’s recent inspections indicate improvement, with the latest visits showing compliance after prior deficiencies were addressed.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
18.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
348% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462173.
Complaint Details
Complaint IN00462173 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00462173 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 7
Medicaid census: 49
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 23, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaints IN00459395 and IN00458151, as well as an unrelated deficiency.
Complaint Details
The visit was related to the Investigation of Complaints IN00459395 and IN00458151. The facility was found to be in compliance.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the investigations.
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 3
Date: May 21, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459395 and IN00458151 related to allegations of misappropriation and pharmaceutical services.
Complaint Details
Complaint IN00459395 involved misappropriation allegations substantiated by evidence of unauthorized use of a resident's debit card by CNA 13. Complaint IN00458151 involved failure to provide pharmaceutical services and follow physician orders for wound care.
Findings
The facility was found deficient in ensuring residents were free from misappropriation, following physician orders for wound care, and providing adequate pharmaceutical services. Specific findings included unauthorized use of a resident's debit card by staff, incomplete wound care treatments and assessments, and failure to provide a prescribed hemorrhoid cream.
Deficiencies (3)
Failed to ensure residents were free from misappropriation; a resident's debit card was used without consent by staff.
Failed to ensure physician orders for wound care were followed and documented for 2 of 3 residents.
Failed to ensure adequate pharmaceutical services; a resident did not receive prescribed hemorrhoid cream due to lack of treatment on hand.
Report Facts
Census: 57
Total Capacity: 57
Medicare Residents: 10
Medicaid Residents: 47
Dates of missed wound care treatments: 15
Date of survey: May 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed the report |
| CNA 13 | Identified as responsible for unauthorized use of resident's debit card | |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding wound care documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care and pharmaceutical services |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding missing hemorrhoid cream |
| Facility Administrator | Facility Administrator | Provided facility policies and interviews |
Inspection Report
Follow-Up
Census: 57
Capacity: 57
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00456171 completed on 3/27/25.
Complaint Details
Complaint IN00456171 was corrected as of this visit.
Findings
Transcendent Healthcare of Boonville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00456171 survey.
Report Facts
Census SNF/NF beds: 57
Census total residents: 57
Census Medicare residents: 10
Census Medicaid residents: 45
Census Other residents: 2
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 3
Date: Mar 27, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00456171 regarding federal and state deficiencies related to resident safety and record-keeping.
Complaint Details
Complaint IN00456171 involved allegations of inadequate supervision leading to resident elopement, incomplete resident records, and failure to report the elopement to the state agency. The complaint was substantiated with deficiencies cited at F689, F842, and F9999.
Findings
The facility failed to provide adequate supervision and a secure environment to prevent a resident with dementia from eloping, failed to maintain complete and accurate resident records including medication administration, and failed to report the elopement event to the state agency in a timely manner.
Deficiencies (3)
Failed to ensure adequate supervision and a secure environment to prevent a resident with dementia from eloping.
Failed to ensure resident records were complete and accurate, including documentation of an elopement event and medication administration records.
Failed to immediately inform the state agency of an unusual occurrence involving resident elopement.
Report Facts
Census: 58
Total Capacity: 58
Medicare Residents: 4
Medicaid Residents: 52
Other Payor Residents: 2
Survey Dates: 2025-03-26 to 2025-03-27
Medication Errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed the report and involved in oversight of the facility |
| RN 10 | Notified Facility Administrator of missing resident and called police to report missing resident | |
| CNA 8 | Discovered resident missing during early morning bed check | |
| QMA 14 | Documented medication administration in error and corrected record | |
| Police Sergeant 4 | Reported resident found outside facility after elopement |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The visit was conducted as a paper compliance review related to the Recertification and State Licensure survey.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 57
Capacity: 102
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered except for two detached structures used for maintenance and storage.
Inspection Report
Life Safety
Census: 60
Capacity: 102
Deficiencies: 7
Date: Feb 12, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) on February 12, 2025.
Findings
The facility was found not in compliance with several Life Safety Code requirements including egress door accessibility, emergency lighting testing documentation, hazardous area door self-closing devices, interior wall and ceiling finish flame spread ratings, smoke barrier door closure, smoking area cleanliness, and maintenance/testing of patient care related electrical equipment. Corrective actions and monitoring plans were provided for each deficiency.
Deficiencies (7)
Failed to ensure the means of egress through 1 of 11 locked exit doors was readily and easily accessible; door required heavy force to open.
Failed to ensure documentation for annual 90-minute testing of 5 battery backup emergency lights was available.
Failed to ensure 2 of over 10 hazardous area doors had self-closing devices and were smoke resistant.
Failed to ensure materials used as interior finish in 1 of 9 smoke compartments had a flame spread rating of Class A or B.
Failed to ensure 1 of 6 sets of smoke barrier doors would close and latch to form a smoke resistant barrier; one half inch gap remained.
Failed to ensure cigarette butts were properly disposed of in the designated smoking area; cigarette butts scattered on ground and in inappropriate containers.
Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 102
Census: 60
Locked exit doors: 11
Battery backup lights: 5
Hazardous area doors: 10
Smoke compartments: 9
Smoke barrier doors: 6
Residents potentially affected: 20
Residents potentially affected: 10
Residents potentially affected: 20
Residents potentially affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed report and participated in exit conference |
| Maintenance Director | Interviewed and acknowledged deficiencies related to exit door, emergency lighting, hazardous area doors, smoke barrier doors, smoking area, and electrical equipment | |
| Maintenance Assistant | Interviewed and acknowledged deficiencies and assisted with observations during survey |
Inspection Report
Annual Inspection
Census: 57
Capacity: 57
Deficiencies: 14
Date: Jan 30, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in January 2025.
Findings
The facility was cited for multiple deficiencies including failure to facilitate care plan meetings, failure to deliver mail on Saturdays, inaccurate assessments, incomplete care plans, failure to revise care plans after resident decline, unsafe environment hazards, incomplete nurse staffing postings, improper medication administration, infection control lapses, and failure to enforce smoking policies.
Deficiencies (14)
Failed to facilitate care plan meetings with residents or representatives for 5 of 6 clinical records reviewed.
Failed to deliver mail to residents on Saturdays as indicated by 11 residents.
Minimum Data Set (MDS) assessments did not accurately reflect resident status for 6 of 17 residents reviewed.
Failed to ensure development and implementation of comprehensive person-centered care plans for 4 of 17 residents reviewed.
Failed to revise resident care plans for decline in ADLs and nutrition for 2 residents.
Failed to provide appropriate treatment and services to maintain or improve ADLs for 1 resident.
Failed to provide adequate supervision and environment free of accident hazards for 3 residents; residents smoked unsupervised and extension cord was unsecured.
Failed to post thoroughly completed nurse staffing sheets daily for 7 days during the survey.
Failed to ensure a resident with dementia received appropriate treatment and services; lacked care plan, safety risk identification, documentation of wandering, and daily routine.
Failed to ensure medications were administered appropriately for 1 of 5 residents; blood pressure medication given without monitoring and opioid overused.
Failed to ensure psychotropic medications were used appropriately for 2 of 5 residents; lacked gradual dose reduction and appropriate diagnosis.
Failed to maintain safe and secure storage of medications; narcotic and loose pills found in medication cart.
Failed to provide safe and sanitary environment; issues with wound care glove use, lack of enhanced barrier precautions for catheter care, unclean and unsafe environmental conditions in resident rooms and shower.
Failed to ensure smoking policy was followed; residents had smoking supplies on person, smoked unsupervised and in undesignated areas, and lacked updated smoking assessments and care plans.
Report Facts
Survey dates: 8
Census: 57
Total capacity: 57
Residents affected by care plan meeting deficiency: 5
Residents affected by unnecessary medication use: 1
Residents with inaccurate assessments: 6
Residents with incomplete care plans: 4
Residents with care plan revision failures: 2
Residents with unsafe environment hazards: 3
Days with incomplete nurse staffing sheets: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed the inspection report |
| RN 23 | Registered Nurse | Named in infection control and medication administration findings |
| QMA 7 | Qualified Medication Aide | Named in medication storage and smoking policy findings |
| LPN 5 | Licensed Practical Nurse | Named in medication administration and care plan findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaints IN00449097 and IN00446323, as well as an unrelated deficiency.
Complaint Details
The visit was complaint-related, reviewing Investigations IN00449097 and IN00446323. The facility was found in compliance with no deficiencies noted.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the investigations.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 2
Date: Dec 16, 2024
Visit Reason
This visit was for the investigation of complaints IN00449082, IN00449097, and IN00446323.
Complaint Details
Complaint IN00449082: No deficiencies related to the allegations are cited. Complaint IN00449097 and IN00446323: Federal/State deficiencies related to the allegations are cited at F921.
Findings
The facility was found deficient in medication and syringe storage security, and maintaining a safe, sanitary, and homelike environment in resident halls. Specific issues included unsecured medications and sharps, damaged flooring, holes in walls, uncovered specimen collection hats, full trash receptacles, and unpleasant odors.
Deficiencies (2)
Failed to ensure medications and syringes were stored safely and securely; discontinued medications and an unsecured sharps container with unused syringes were stored in an unlocked conference room.
Failed to ensure a safe, sanitary, and homelike environment in resident halls; issues included holes in walls, floors in disrepair, uncovered specimen collection hats, full trash receptacles, and odors present.
Report Facts
Resident census: 60
Total licensed capacity: 60
Medicare residents: 8
Medicaid residents: 52
Unused syringes in unsecured sharps container: 30
Levofloxacin tablets: 19
Vitamin D3 tablets: 3
Juven Oral Packets: 20
Scopolamine Base Patch: 1
Resident rooms with planned repairs: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed report and involved in quality assurance monitoring |
| Director of Nursing | Interviewed regarding medication removal from conference room | |
| LPN 8 | Interviewed regarding medication and syringe storage | |
| Minimum Data Set (MDS) Nurse | Interviewed regarding syringe storage | |
| Facility Administrator | Provided facility policies | |
| Maintenance Director | Interviewed regarding facility repairs and housekeeping |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
This visit was conducted to investigate complaints IN00440411, IN00440423, and IN00440890 at Transcendent Healthcare of Boonville.
Complaint Details
Complaint IN00440411: No deficiencies cited. Complaint IN00440423: No deficiencies cited. Complaint IN00440890: No deficiencies cited.
Findings
No deficiencies were cited related to the allegations in any of the three complaints investigated. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 2
Inspection Report
Re-Inspection
Census: 51
Capacity: 51
Deficiencies: 0
Date: Jul 12, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00434692, following the survey completed on 2024-06-03.
Complaint Details
Complaint IN00434692 was investigated and found to be corrected.
Findings
Transcendent Healthcare of Boonville was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00434692.
Report Facts
Census SNF/NF beds: 51
Total census: 51
Medicare census: 9
Medicaid census: 40
Other payor census: 2
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 1
Date: Jun 3, 2024
Visit Reason
This visit was for the investigation of complaints IN00435502, IN00434692, and IN00433712, specifically addressing allegations related to resident safety and elopement risk.
Complaint Details
Complaint IN00434692 was substantiated with deficiencies cited at F689 related to elopement risk and supervision failures. Complaints IN00435502 and IN00433712 had no deficiencies cited.
Findings
The facility failed to provide adequate supervision to prevent a resident with dementia and a history of elopement from exiting the facility through a window, resulting in an elopement incident on 5/14-5/15/24. Immediate Jeopardy was identified but removed after corrective actions including staff in-service, securing windows, and implementing elopement risk interventions. Noncompliance remained at a lower severity level with ongoing monitoring.
Deficiencies (1)
Facility failed to ensure adequate supervision to prevent a resident with dementia and elopement risk from exiting the facility through a window, resulting in an elopement incident.
Report Facts
Residents reviewed for elopement and risk for wandering: 4
Survey dates: May 30, 31, and June 3, 2024
Resident C elopement incident date: Night of 5/14/24 to early morning 5/15/24
Distance resident was located from facility: 22
Elopement risk score threshold: 11
Duration of emergency protective services order: 45
Census: 52
Total licensed capacity: 52
Inspection Report
Life Safety
Census: 51
Capacity: 102
Deficiencies: 0
Date: May 30, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and life safety code requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered except for two detached structures used for maintenance and storage.
Report Facts
Facility capacity: 102
Census: 51
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 29, 2024
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) to the PSR to the Recertification and State Licensure Survey completed on April 25, 2024.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the PSR to the PSR to the Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 57
Capacity: 57
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-03-14, including a PSR to the Investigation of Complaint IN00428375 completed on 2024-03-14. The complaint was corrected.
Complaint Details
Complaint IN00428375 was investigated and corrected as part of this Post Survey Revisit.
Findings
The facility failed to ensure safe and sanitary storage of food in the kitchen, with observations of unlabeled and open food items, debris on floors, ice accumulation in refrigeration units, and incomplete temperature logs. Corrective actions included deep cleaning, discarding outdated food, labeling and sealing food items, and staff re-education on food safety policies.
Deficiencies (1)
Failed to ensure storage of food in a safe and sanitary manner; open food items unlabeled and open to air, debris on floor, ice accumulation in refrigerator and freezer, and temperature logs not up to date.
Report Facts
Census: 57
Total Capacity: 57
Medicare Census: 16
Medicaid Census: 40
Other Payor Census: 1
Temperature Log Missing Dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed the report |
| Dietary Manager | Provided temperature logs and interviewed regarding food safety practices | |
| Maintenance Director | Verified freezer temperature |
Inspection Report
Life Safety
Census: 52
Capacity: 102
Deficiencies: 13
Date: Apr 1, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and Emergency Preparedness Survey conducted in accordance with 42 CFR 483.73.
Findings
The facility was found not in compliance with several Life Safety Code requirements including delayed egress door signage, exit door accessibility, illumination of means of egress, exit signage, hazardous area door closures, interior wall and ceiling finish fire rating, fire alarm system testing and maintenance, sprinkler system installation and maintenance, electrical safety, HVAC combustion air intake, and fire safety plan completeness. Corrective actions and staff education plans were provided for each deficiency.
Deficiencies (13)
Delayed egress locks lacked required signage and keypad codes; one exit door required heavy force to open.
Illumination of means of egress was not properly maintained; one light bulb missing in exit discharge lighting.
Exit door to courtyard lacked 'NO EXIT' signage.
Laundry dryer room door did not close completely and latch automatically.
Smoke compartment interior finish did not have required Class A or B flame spread rating due to plywood attic access panel.
Fire alarm system lacked documentation of semi-annual visual inspection of devices such as smoke and heat detectors.
Fire alarm system out of service policy incomplete and inaccurate.
Sprinkler system missing coverage or fire retardant documentation for two exterior canvas canopies.
Two of three sprinkler system gauges on riser not replaced or calibrated within five years; one sprinkler head corroded and not replaced.
Sprinkler system out of service policy incomplete and inaccurate.
Electrical receptacle loose and protruding; junction box in basement missing cover exposing wiring.
Laundry dryer room lacked intake combustion air vent from outside for fuel fired dryers.
Fire safety plan incomplete; missing smoke barrier locations, staff response to battery operated smoke alarms, K-class extinguisher use, wheeled equipment removal, and alarm transmission to fire department.
Report Facts
Certified beds: 102
Census: 52
Deficiencies cited: 13
Sprinkler gauge replacement interval: 5
Delayed egress locks observed: 11
Exit doors observed: 11
Smoke compartments: 9
Sprinkler system risers: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed report and involved in exit conference |
| Maintenance Supervisor | Interviewed and acknowledged multiple deficiencies including door signage, lighting, sprinkler gauges, fire alarm inspections, electrical issues, HVAC combustion air, and fire safety plan |
Inspection Report
Recertification
Census: 52
Capacity: 52
Deficiencies: 23
Date: Mar 14, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00428375.
Complaint Details
Complaint IN00428375 was investigated during this recertification survey. Federal/State deficiencies related to the allegations were cited at F623 and F625.
Findings
The facility was found deficient in multiple areas including resident dignity, medication administration, notification of changes, reporting and investigation of alleged violations, transfer/discharge notices, care plan accuracy and revision, infection control, call light functionality, environmental safety, and staffing requirements.
Deficiencies (23)
Failure to ensure residents were treated with dignity; uncovered catheter bags, soiled clothing, and delayed meal tray removal observed.
Failure to assess residents for capability to self-administer medications and improper medication storage.
Failure to notify physician and resident representative of significant changes including weight loss and use of electronic cigarette.
Failure to report and investigate alleged misappropriation of medications and failure to report to State Survey Agency.
Failure to provide proper notice of transfer/discharge and bed hold policy to residents, representatives, and ombudsman.
Inaccurate Minimum Data Set (MDS) assessments for multiple residents.
Failure to develop and implement comprehensive person-centered care plans reflecting resident needs and conditions.
Failure to review and revise care plans after assessments and changes in resident condition.
Failure to provide ongoing activity programs meeting resident interests; activities director unavailable.
Failure to provide treatment and services to promote healing of pressure ulcers; wound vac order missing and wound left open to air.
Failure to provide adequate supervision and interventions to prevent accidents and falls; neuro checks not documented after falls.
Failure to provide necessary behavioral health monitoring and care plans for residents with behaviors.
Failure to provide medically-related social services; missing dentures not addressed; resident left facility without physician order.
Failure to ensure accurate medication administration and documentation; missing doses of controlled substances.
Failure to serve food at safe and appetizing temperatures; lunch tray foods served below recommended temperatures.
Failure to store food in a safe and sanitary manner; unlabeled open food, debris on kitchen floor, damaged window screen and dirty air conditioning unit.
Failure to maintain accurate medical records; resident left facility on leave of absence without physician order or proper documentation.
Failure to maintain a safe, functional, sanitary, and comfortable environment; multiple environmental deficiencies including dirty shower rooms, broken blinds, damaged flooring, and unclean bathrooms.
Failure to maintain current licensure for contracted beautician.
Failure to provide 8 consecutive hours of RN coverage 7 days a week on 2 days reviewed.
Failure to post nurse staffing sheets daily with accurate information on 3 of 9 days reviewed.
Failure to provide necessary infection prevention and control program elements; resident with MRSA lacked contact precautions and care plan; catheter bag dragging on floor; no water system monitoring for Legionella.
Failure to ensure resident call lights were functioning and within reach for residents; call lights found on floor or hanging out of reach.
Report Facts
Residents present: 52
Survey dates: 9
Weight change: 50
Weight loss: 13.8
Missing doses: 2
Falls: 5
Falls: 4
Call light malfunctions: 4
RN coverage hours missing: 2
Days nurse staffing sheets missing or incorrect: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed report and involved in plan of correction |
| RN 9 | Registered Nurse | Involved in medication administration and documentation errors for Resident J |
| LPN 5 | Licensed Practical Nurse | Involved in medication administration and documentation errors for Resident J |
| QMA 25 | Qualified Medication Aide | Involved in medication administration and documentation errors for Resident J |
| QMA 27 | Qualified Medication Aide | Involved in medication administration and documentation errors for Resident J |
| CNA 18 | Certified Nurse Aide | Involved in call light placement and falls prevention |
| CNA 3 | Certified Nurse Aide | Involved in call light placement and resident care |
| LPN 21 | Licensed Practical Nurse | Involved in call light placement and medication administration |
| Maintenance Supervisor | Involved in environmental maintenance and call light repair | |
| Kitchen Manager | Involved in food safety and sanitation | |
| ADON | Assistant Director of Nursing | Involved in multiple findings including infection control, medication errors, care plans, and staffing |
| MDS Coordinator | Involved in MDS assessment accuracy and care plan revisions | |
| SSD | Social Services Director | Involved in social services and grievance handling |
| Business Office Manager | Involved in oversight of beautician licensure | |
| Beautician | Contracted staff with expired license |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
This visit was conducted for the investigation of four complaints (IN00427637, IN00427030, IN00426889, and IN00426916). Two complaints had no deficiencies cited, while two complaints resulted in state deficiencies.
Complaint Details
The investigation involved four complaints: IN00427637 and IN00427030 had no deficiencies cited; IN00426889 and IN00426916 had state deficiencies related to failure to report an unusual occurrence involving heating system failure and resident relocation. The complaints were substantiated with deficiencies cited.
Findings
The facility failed to report an unusual occurrence involving a heating system failure on the South wing of the West unit, which required relocating residents for approximately six days. Eleven residents were affected but no harm was reported. The facility implemented corrective actions including repairs, resident relocation, staff in-service training, and a Quality Assurance monitoring tool to prevent recurrence.
Deficiencies (1)
Failure to immediately inform the state agency of an unusual occurrence when the heating system failed on the South wing of the West unit, requiring resident relocation.
Report Facts
Residents relocated: 11
Census: 56
Medicare residents: 8
Medicaid residents: 47
Other payor residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin L McCarty | Executive Director | Signed report and responsible for facility management |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00421569, which included federal/state deficiencies related to the allegations cited at F677, F686, and F880.
Complaint Details
Complaint IN00421569 was investigated with deficiencies cited related to ADL care, pressure ulcer treatment, and infection control.
Findings
The facility was found deficient in providing adequate ADL care to a resident, failed to provide treatment or notify the physician of suspected deep tissue injury for a resident with pressure wounds, and failed to ensure proper infection control practices including hand hygiene and glove use during care.
Deficiencies (3)
Failed to provide ADL care to 1 of 1 residents observed for ADL care (Resident B).
Failed to provide treatment or notify physician of suspected deep tissue injury for 1 of 3 residents reviewed for pressure wounds (Resident C).
Failed to ensure infection control practices were done for 1 of 3 residents observed for care; hand hygiene was not done and gloves were not changed (Resident B).
Report Facts
Census: 51
Total Capacity: 51
Medicare Census: 7
Medicaid Census: 43
Other Payor Census: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin McCarty | Executive Director | Signed report and referenced in administrative capacity |
| CNA 1 | Named in infection control and ADL care deficiencies | |
| CNA 2 | Named in infection control and ADL care deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 7, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00421569.
Complaint Details
Investigation of Complaint IN00421569; paper compliance review found facility in compliance.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 1
Date: Sep 20, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00417535 regarding allegations of improper use of physical restraints on a resident.
Complaint Details
Complaint IN00417535 was substantiated with federal/state deficiencies cited related to the allegations of improper use of physical restraints on Resident C.
Findings
The facility failed to ensure that residents were free from physical restraints for 1 of 1 residents reviewed. Resident C was placed in a new wheelchair with straps that restricted mobilization without documented clinical rationale, assessments, or a plan of care for the use of restraints.
Deficiencies (1)
Failure to ensure residents were free from physical restraints; Resident C was strapped into a wheelchair without documented clinical rationale, assessments, or plan of care.
Report Facts
Census: 55
Total Capacity: 55
Medicare Census: 4
Medicaid Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline K Morris | Executive Director | Signed the report |
| QMA 23 | Interviewed regarding Resident C's use of restraints and wheelchair | |
| OT 4 | Occupational Therapist | Interviewed regarding Resident C's wheelchair and positioning |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding restraint release and assessment practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00417535.
Complaint Details
Investigation of Complaint IN00417535; facility found in compliance.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00408040 and IN00411107.
Complaint Details
Complaint IN00408040 and Complaint IN00411107 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 58
Total Capacity: 58
Medicare Census: 12
Medicaid Census: 43
Other Payor Census: 3
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 2
Date: Jan 10, 2023
Visit Reason
This visit was for the investigation of complaint IN00391528, which was substantiated with federal/state deficiencies cited at F656 and F690.
Complaint Details
Complaint IN00391528 was substantiated with deficiencies related to diabetic care and incontinent/catheter care.
Findings
The facility failed to ensure the comprehensive care plan was implemented for diabetic residents, resulting in missed insulin doses and failure to notify physicians of high blood sugar levels. Additionally, the facility failed to provide proper incontinent and catheter care, including inadequate hand hygiene and delayed treatment of urinary tract infections for residents with incontinence or catheters.
Deficiencies (2)
Failure to develop and implement a comprehensive care plan ensuring diabetic residents received insulin as ordered and physicians were notified of abnormal blood sugar levels.
Failure to provide appropriate incontinent and catheter care, including proper hand hygiene and timely treatment of urinary tract infections.
Report Facts
Census: 52
Total Capacity: 52
Deficiencies cited: 2
Insulin doses missed: 7
Blood sugar level: 407
Antibiotic treatment duration: 10
Hand hygiene scrub time: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Preusz | Executive Director | Signed report |
| QMA 4 | Interviewed regarding insulin administration and physician notification | |
| CNA 5 | Observed providing incontinent and catheter care, hand hygiene practices | |
| CNA 6 | Observed providing incontinent and catheter care, hand hygiene practices | |
| DON | Director of Nursing | Interviewed regarding lab result review and care practices |
| AIT | Administrator in Training | Provided facility policies during interview |
| Infection Preventionist | Interviewed regarding lab results and antibiotic treatment decisions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00391528.
Complaint Details
Investigation of Complaint IN00391528; paper compliance review completed with findings of compliance.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00388756 conducted on September 8, 2022.
Complaint Details
Investigation of Complaint IN00388756; paper compliance review found the facility in compliance.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Date: Sep 7, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00389601 and IN00388756. Complaint IN00389601 was unsubstantiated due to lack of evidence, while complaint IN00388756 was substantiated with related federal/state deficiencies cited.
Complaint Details
Complaint IN00389601 was unsubstantiated due to lack of evidence. Complaint IN00388756 was substantiated with federal/state deficiencies cited related to care plan development and updates.
Findings
The facility failed to ensure individual comprehensive care plans were developed and updated for 3 of 4 residents reviewed for accidents, including fall and wandering risks. Specific residents lacked appropriate plans or updated interventions to prevent falls and wandering. The facility implemented corrective actions including care plan revisions, staff in-service training, and quality assurance monitoring to prevent recurrence.
Deficiencies (1)
Failure to develop and implement comprehensive person-centered care plans for residents at risk for falls and wandering.
Report Facts
Census: 49
Total Capacity: 49
Medicare Census: 21
Medicaid Census: 26
Other Payor Census: 2
Fall incidents for Resident G: 2
Fall incident for Resident C: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00385189 and IN00382962.
Complaint Details
Investigation of Complaint IN00385189 and IN00382962; paper compliance review completed with findings of compliance.
Findings
Transcendent Healthcare Boonville was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaints.
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