Transcendent Healthcare Of Boonville

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the

interview and record review, the facility failed to update or revise the care plan for 1 of 3 residents reviewed for advance directives. A resident's code status was not updated in the plan of care. (Resident B)Finding includes:During record review on [DATE REDACTED] at 10:05 A.M., Resident B's Advance Directive Form, dated [DATE REDACTED], indicated the resident chose Do Not Attempt Resuscitation (DNR) should the resident have no pulse and stop breathing.Resident B's care plan included, but was not limited to, Resident is a Full Code Attempt Cardiopulmonary Resuscitation (CPR) (initiated [DATE REDACTED] and revised and canceled on [DATE REDACTED]) with

the goal; if the resident's heart/breathing stops, please start CPR through the target date [DATE REDACTED] (Cancelled [DATE REDACTED]).Resident B's nurses' progress notes included, but were not limited to: [DATE REDACTED] at 2:37 P.M. Resident B's date of death [DATE REDACTED]. Time of death 2:37 P.M.During an interview on [DATE REDACTED] at 11:00 A.M., the Social Service Director (SSD) indicated a change of code status should be uploaded into the resident's

record and the plan of care should be updated at that time. On [DATE REDACTED] at 11:15 A.M., the Director of Nursing (DON) supplied an undated facility policy titled, Advanced Directives. The policy included, .If the Resident Has an Advanced Directive . 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive . 8. Changes or revocations of a directive must be submitted in writing to the administrator . The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan .This citation relates to Intake 2618600.3.1-35(d)(2)(B)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and ensure residents were free from accident hazards for 1 of 3 resident reviewed for smoking. Resident areas contained a cigarette smoke odor and a resident indicated smoking in his room without supervision and against facility policy. (West Hall, Resident C) Finding includes:During an observation on 10/6/25 at 12:00 P.M., the back of [NAME] Hall contained an odor of cigarette smoke. During an observation on 10/7/25 at 9:35 A.M., the back of [NAME] Hall contained an odor of cigarette smoke. During a confidential interview, a resident indicated being aggravated that Resident C did not adhere to the facility's smoking rules and smoked in his room. During an observation and interview on 10/7/25 at 9:40 A.M., Resident C was sitting up on his bed in his room. Resident B indicated that Resident C had smoked cigarettes in his room the night prior. During an interview on 10/7/25 at 9:45 A.M., QMA 4 indicated residents were not allowed to smoke in the facility and that residents should not have cigarettes or a lighter in their possession. Smokers are given their cigarettes during designated smoking times in the smoking area while they are supervised by a staff member. During record review on 10/7/25 at 10:00 A.M., Resident C's diagnoses included but were not limited to tobacco use, nicotine dependence, chronic obstructive pulmonary disease (COPD), polyneuropathy, and unspecified mental disorder. Resident C's most recent quarterly minimum data set (MDS) assessment, dated 9/4/25, indicated the resident had no cognitive impairment. Resident C's most recent smoking safety assessment, dated 8/26/25, indicated the resident used tobacco and the resident had burn marks on his skin/clothing/or furniture. The smoking assessment indicated supervision, designated smoking areas, and smoking times were determined by facility policy. Resident C's nurses' progress notes included, but were not limited to:9/10/25 at 8:16 A.M. - Resident smoking in his bathroom.

The resident had taken cigarette butts from the ashtray outside. 9/11/25 at 11:47 A.M. - Resident again with smoking items and smoking in the facility. On 10/7/25 at 11:15 A.M., the Director of Nursing (DON) supplied

an undated facility policy titled Smoking Policy - Residents. The policy included, This facility has established and maintains safe resident smoking practices . 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building . Smoking is not allowed inside the facility under any circumstances . 12. All smoking materials are to be kept at the nurse's station and will be distributed at each designated smoke time .This citation relates to intake 2618600.3.1-45(a)(1)

Event ID:

Facility ID:

If continuation sheet