Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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 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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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 | — | 10 | 0 |
| Woodmont Health Campus | 3.6 mi | — | 8 | 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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