Transcendent Healthcare of Boonville - North

Inspectors wroteBased on interview and record review, the facility failed to establish a facility-wide system to prevent, identify, report, investigate, and control infections for 4 of 5 residents reviewed for hospitalizations (Resident 27, Resident 19, Resident 1, and Resident 48). Residents who experienced upper respiratory symptoms were not tested or treated for influenza. The facility did not investigate the cause of or track residents' signs and symptoms. This deficient practice resulted in Resident 27, Resident 1, and Resident 48 being hospitalized . Residents tested positive for influenza A upon arriving at the hospital. Resident 19 was ordered to be sent to the hospital, but expired before she could get there. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure fall prevention measures were in place for 1 of 2 residents reviewed for falls resulting in major injury. This deficient practice resulted in a fall with a brain bleed. (Resident 5)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the kitchen manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. (Food Services Director)

Inspectors wroteBased on record review and interview, 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 related to the Infection Preventionist and Medical Director, or designee, and Director of Nursing not being present. This had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a designated infection preventionist was onsite to implement programs and activities to prevent and control infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were properly secured, failed to keep insulin refrigerated until opened, and to label and date vials of tuberculin solution with open and expiration dates for 2 of 2 medication carts and the [Pharmacy Name] Medication room refrigerator. (West Medication Cart, East Medication Cart, [Pharmacy Name] Medication Room) FIndings include: 1, On 2/9/26 at 2:19 P.M., during random observation of the [NAME] Medication Cart the following was observed:1 unopened Lantus pen for Resident 26 with no open date or expiration date1 open Lispro insulin pen for Resident 4 with no open date or expiration date 2. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a sink in a therapy restroom was safely secured to the wall and personel belongings in shared restrooms were labeled with resident names in 4 of 4 shared restrooms reviewed.( Sink in therapy area restroom, Shared restrooms between rooms [ROOM NUMBERS], rooms [ROOM NUMBERS], rooms [ROOM NUMBERS], rooms [ROOM NUMBERS])

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for 1 of 1 residents reviewed for Urinary Tract Infection (UTI) and 1 of 1 residents reviewed for Respiratory Care. A care plan was not developed for residents for use of antibiotics and oxygen use. (Resident 3, Resident 34)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure interventions were in place for 1 of 2 resident reviewed for falls. An intervention for falls was not implemeted.(Resident 21)

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented a clinical contraindication when a gradual dose reduction (GDR) was declined for 3 of 5 residents reviewed for unnecessary medications (Resident 2, Resident 4, and Resident 33).

Inspectors wroteBased on interview and record review, the facility failed to ensure vaccinations were provided according to residents' informed consent for 2 of 6 residents reviewed for immunizations. A resident who consented to receive the influenza vaccine did not receive it. A resident who declined to receive the influenza vaccine did receive it. (Resident 48 and Resident 33)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent a resident with a history of exit-seeking/elopement behavior from exiting the facility and leaving the property for 1 of 3 residents reviewed for elopement. This deficient practice resulted in an elopement that occurred during the morning hours of September 1, 2025. The resident was located with the assistance of the local police department, approximately 1.2 miles from the nursing facility, near a previous residence. This Immediate Jeopardy began on September 1, 2025, when the facility failed to ensure Resident C did not exit the facility property through a doorway on the [NAME] Hall at approximately 5:30 A.M. Resident C was not realized to be missing until 7:15 A.M. after staff noticed she was not in her room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the plan of care for 1 of 1 residents observed for catheter care. Catheter care orders and treatments were not completed per the physician orders and the plan of care. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage of at least 8 hours daily. Weekend RN coverage did not include at least eight (8) hours on two occasions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident without pressure-related skin impairment did not develop a pressure injury for 1 of 2 residents reviewed for pressure injuries. Following the development of a pressure ulcer, no initial assessment was documented, and no documented treatment was given for 4 days and interventions were not routinely documented as completed by the plan of care. This deficient practice resulted in Resident 12 developing a facility acquired stage III pressure ulcer (Full-thickness skin loss with damage to subcutaneous tissue. The ulcer may extend into the subcutaneous tissue layer. Granulation tissue and epibole [rolled wound edges] are often present. No exposure of bone, tendon, or muscle. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored under proper temperature controls for 1 of 1 medication storage rooms reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents observed during medication pass and 4 of 4 residents reviewed for use of Enhanced Barrier Precautions (EBP). A pill was dropped on the medication cart, touched with a bare hand, and administered to the resident. Residents with indwelling catheters and open wounds were not placed on precautions as indicated. (Resident 12, Resident 44, Resident 54, Resident 205, Resident 2)

Inspectors wroteBased on observation, interview and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 1 resident admitted on hospice. One resident failed to have orders for hospice and oxygen. (Resident 204)

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive assessment was completed within 14 days after admission for 1 of 5 residents reviewed that were admitted in the last 30 days. A resident admitted on [DATE] did not have a comprehensive assessment completed within 14 days of admission. (Resident 205)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident specific plan of care was developed for 2 of 14 resident care plans reviewed. A dependent resident was not care planned for ADL's (Activities of Daily Living) and a resident at nutritional risk was not care planned timely following an unplanned significant weight loss. (Resident 25, Resident 44)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a new diagnosis of schizophrenia followed the professionally accepted diagnostic process for 1 of 5 residents reviewed for unnecessary medications. A resident received a diagnosis of schizophrenia without documented screening/testing or symptoms. (Resident 25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate nutrition was maintained for 1 of 2 residents reviewed for nutrition. The registered dietitian did not document a review of a resident's significant weight loss and no plan of care was created following a nutritional assessment that indicated the resident was at risk, and no plan of care was created immediately following a significant weight loss. (Resident 25)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were certified as CNAs (Certified Nurse Aides) within 120 days of hire date for 3 of 10 CNAs reviewed for certification.

Inspectors wroteBased on interview and record review, the facility failed to provided RN coverage for 8 a day. The nursing schedule reviewed lacked RN coverage for at least 8 hours a day for 3 of 5 weekends reviewed.

Inspectors wroteBased on interview and record review, the facility failed to complete thorough assessments and to provide behavioral monitoring for 2 of 4 residents reviewed for behaviors. Lack of monitoring led to an altercation between residents. (Resident K, Resident H)

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans and follow interventions to reduce the risk of falls for 2 of 4 residents reviewed for accidents. This deficient practice resulted in a fall with fractures requiring hospitalization and a fall with a closed head injury requiring hospitalization. (Resident M, Resident P).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment. for 1 of 1 laundry areas and 3 of 3 resident halls. Washers had debris build up, floors had debris build up, and point of contact water temperatures were over 122 degrees F (Fahrenheit).

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were revised for 3 of 3 residents (Resident 16, Resident 27, Resident 38) and lacked documentation of care plan conferences being completed for 11 of 13 residents reviewed for care plan conferences (Resident 1, Resident 14, Resident 16, Resident 20, Resident 46, Resident 7, Resident 22, Resident M, Resident S, Resident F, Resident P)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident dignity was respected for 2 of 2 residents during 3 random observations. (Resident P, Resident 48)

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify appropriate parties after a significant change in resident status for 1 of 1 residents reviewed for insulin and 1 of 3 residents reviewed for nutrition. (Resident T, Resident P)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 2 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for insulin. (Resident 7, Resident P, Resident F)

Inspectors wroteBased on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 1 residents reviewed for insulin. A resident did not receive insulin as ordered, and the physician was not notified of blood sugars over 400 as ordered. (Resident T)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received necessary respiratory care and services in accordance with professional standards of practice for 3 of 3 residents reviewed for Respiratory Care. Care plans and orders were not revised, and tubing and humidification bottle changes were not documented. (Resident 14, Resident 46, Resident 7)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with dementia received the appropriate treatment and services to maintain their highest level of well-being for 1 of 2 residents reviewed for dementia care. (Resident F)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 1 residents reviewed for insulin and 2 of 5 residents reviewed for unnecessary medications. Residents' as needed anti-anxiety medication was ordered for greater than 14 days (Resident 7, Resident T. Resident P).

Inspectors wroteBased on interview and record review, the facility failed to ensure dental services were provided for 2 of 2 residents reviewed for dental. Residents were not referred to a dentist for acute dental pain or to obtain replacement dentures. (Resident 22, Resident P)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene was done for 2 of 6 observations of medication administration (Resident L, Resident B) and 1 of 1 observation of a dressing change (Resident T), and the facility failed to ensure toothbrushes were labeled and covered for 1 random observation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide training to staff assigned to supervise residents who smoke for 1 of 1 resident reviewed for smoking. A resident violated the facility's smoking policy and the designated staff were not trained in how to handle the situation. (Resident 22)

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was disposed of properly for 2 of 2 dumpsters observed on the northwest side of the building. The dumpster was left open and trash bags were not closed and were on the ground around the dumpster.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility was sufficiently staffed for 1 of 1 quarters reviewed. Low weekend staffing was triggered by the CMS (Centers for Medicare and Medicaid Services) PB&J. (Payroll Based Journal) (April, May, June, 2023)