F 0602 During an interview on 5/21/25 at 11:40 A.M., the Facility Administrator indicated the facility did not have a written policy related to shopping or making purchases for residents. The Facility Administrator indicated the Level of Harm - Minimal harm or CNA's and nursing staff were not permitted to make purchases for residents, and that only department heads potential for actual harm or the facility Activity Director could make purchases on a resident's behalf, with the resident's permission.

Residents Affected - Few On 5/19/25 at 11:55 A.M., the Facility Administrator supplied an undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. The policy included, All reports of . theft/misappropriation of resident property are reported to local, state and federal agencies .

3.1-28(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 155508 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155508 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Transcendent Healthcare of Boonville 725 S Second St Boonville, IN 47601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Right Heel: Cleanse with wound cleanser, pat dry. Cover with bordered gauze dressing, initial and date every day shift for wound care (started 4/11/25 and discontinued 4/19/25) - not completed 4/11/25, 4/15/25, and Level of Harm - Minimal harm or 4/19/25. potential for actual harm Right Heel: Cleanse with wound cleanser, pat dry. Cover with bordered gauze dressing. Initial and date Residents Affected - Few every day shift for wound care (started 4/20/25 and discontinued 5/20/25) - not completed 4/20/25, 4/21/25, 4/29/25, 4/30/25, 5/4/25, 5/12/25, and 5/18/25.

Check placement of dressing to right heel every shift and replace if not present every shift (started 4/19/25) - 4/20/25 (day shift), 4/21/25 (day shift), 4/29/25 (day shift), 4/30/25 (day shift), 5/4/25 (day shift), 5/12/25 (day shift), 5/14/25 (nightshift), and 5/18/25 (day shift).

During an interview on 5/21/25 at 12:30 P.M., the Director of Nursing (DON) indicated some of the uncompleted treatment orders were due to the resident having an order completed by an outside source, however could not provide a rational for not providing all treatment orders.

During an interview on 5/21/25 at 1:20 P.M., LPN 4 indicated a residents routine treatment orders should be documented as completed in the resident's record or if the treatment was not provided, a reason should be documented.

On 5/21/25 at 1:25 P.M., the Facility Administrator provided an undated facility policy titled, Medication and Treatment Orders. The policy included, Orders for medications and treatments will be consistent with principles of safe and effective order writing.

This Federal tag relates to complaint IN00458151.

3.1-35(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 155508 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155508 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Transcendent Healthcare of Boonville 725 S Second St Boonville, IN 47601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 39130

Residents Affected - Few Based on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine treatments for 1 of 3 residents reviewed for pharmaceutical services. A facility did not have a treatment on hand and could not provide proof that the treatment (ointment) had been delivered by the pharmacy. (Resident C)

Finding include:

During an interview on 5/21/25 at 12:50 P.M., Resident C indicated that he typically received his ordered medications, however he had not been receiving a routine hemorrhoid cream and had asked for multiple times.

During record review, Resident C's diagnoses included, but were not limited to, anxiety, irritable bowel syndrome, and hypertension.

Resident C's physician orders included but were not limited to; 2-BAD Cream Baclofen/Diltiazem/Amitriptyline topical: apply to hemorrhoids twice a day to reduce inflammation/pain related to rectal fissure (started 3/20/25).

During an interview on on 5/21/25 at 1:00 P.M., the Assistant Director of Nursing (ADON) indicated Resident C's hemorrhoid cream was not in the medication cart but should be in the treatment cart on the front hall of

the building. The ADON indicated that she had not administered the resident's routine dose yet that shift.

The ADON then searched the treatment cart and could not locate the resident's hemorrhoid cream.

During an interview on 5/21/25 at 1:45 P.M., the Director of Nursing (DON) indicated she was unable to locate a pharmacy delivery receipt for Resident C's ordered hemorrhoid cream.

On 5/21//25 at 1:25 P.M., the Facility Administrator supplied an undated facility policy titled, Medication and Treatment Orders. The policy included, .11. Drugs and biologicals that are required to refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available .

This citation relates to complaint IN00459395.

3.1-25(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 155508