Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gentle Care Strategies during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop or implement comprehensive care plans for five residents with specific needs, including those on aspirin therapy, oxygen, self-administered eye drops, and those using a bedside urinal. These omissions were identified through record review, observation, and staff interviews, revealing that the residents' individualized needs and preferences were not formally addressed in their care plans.
Care plans for several residents were not updated after changes in their medical condition or treatment, including continued references to antibiotic use, fracture care, and antipsychotic medication after these were no longer relevant. The MDS Coordinator confirmed that care plans should have been revised to reflect current resident needs, but this was not done in accordance with facility policy.
A medication cart was found to contain clear medication cups with loose controlled substances, including tramadol, Ativan, and hydrocodone-acetaminophen, for three residents. These medications were not stored under double lock as required by facility policy and confirmed by the DON.
A resident with dementia exited a facility unsupervised due to inadequate supervision and a failure of the emergency exit door alarm. Despite wearing a WanderGuard bracelet, the alarm did not sound when the resident exited. The resident, who had a history of wandering, was found outside with minor injuries. Staff failed to notify administrative personnel of the resident's exit-seeking behavior earlier in the night, and documentation of 15-minute safety checks was inconsistent.
The facility failed to provide the required written notification for transfer and discharge to a resident's representative. The resident, diagnosed with hepatic encephalopathy, was sent to the hospital twice, but the clinical record lacked documentation of the Notice Transfer and Discharge forms being provided to the resident and their representative. The DON confirmed that the forms were sent with the resident but not to the representative, and the facility's policy did not require this action.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents with specific clinical needs. Two residents were prescribed and receiving aspirin (ASA) as an antiplatelet medication, but their clinical records did not include care plans addressing this therapy. Another resident, who was observed using a urinal at the bedside and had a history of ESBL bacteria in the urine, did not have a care plan reflecting his preference and practice of using a urinal and keeping it on the bedside table. Additionally, a resident with chronic respiratory failure and pulmonary fibrosis was receiving continuous oxygen therapy per physician order, but there was no care plan in place for oxygen use. Finally, a resident who self-administered eye drops, as permitted by physician order, lacked a care plan addressing self-administration of medication. These deficiencies were identified through observation, interview, and record review, and were confirmed by staff interviews and review of facility policy. The absence of individualized care plans for these residents meant that their specific needs and preferences, as well as the services required to maintain their highest practicable well-being, were not formally documented or addressed in accordance with facility policy and regulatory requirements.
Failure to Timely Revise Care Plans After Changes in Resident Condition and Treatment
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised in a timely manner for multiple residents, as required. For one resident who completed a course of antibiotics, the care plan continued to include interventions related to antibiotic administration and monitoring even after the medication was discontinued. Another resident's care plan still referenced fracture care for a left humerus fracture, despite the absence of a current diagnosis or physician orders related to a fracture. Additionally, a third resident's care plan included interventions for antipsychotic use, although the antipsychotic medication had been discontinued and was no longer part of the resident's treatment regimen. These deficiencies were identified through clinical record reviews, interviews, and examination of care plans and medication administration records. The MDS Coordinator confirmed responsibility for care plan revisions and acknowledged that care plans should have been updated to reflect changes in residents' conditions and treatments. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change, but this process was not followed for the residents in question.
Controlled Substances Not Properly Secured in Medication Cart
Penalty
Summary
The facility failed to ensure the safe and secure storage of controlled substances for one of two medication carts observed. During an observation, a medication cart on the 100 hall was found to contain three clear medication cups, each holding a controlled substance: one tramadol 50 mg tablet for one resident, one Ativan 0.5 mg tablet for another resident, and one hydrocodone-acetaminophen 5-325 mg tablet for a third resident. These controlled substances were not stored under double lock as required. The DON confirmed during an interview that controlled substances should always be stored under double lock. The facility's current policy, revised in January 2024, also specifies that controlled medications must be stored under double lock.
Resident Elopes Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
The facility failed to ensure adequate supervision and a secured environment for a resident with dementia, leading to the resident exiting the facility unsupervised. On the morning of 9/21/24, during 15-minute safety checks, staff noticed the resident was missing at 5:20 A.M. The resident was found outside the Hall 2 emergency exit door, having apparently fallen while unsupervised. The resident had a small abrasion on her palms and a scant amount of fresh blood around her left temple area. The resident was assessed and assisted back into the facility. The resident, who had a history of wandering and elopement, was wearing a WanderGuard bracelet, which is supposed to trigger door alarms and lock monitored doors to prevent unsupervised exits. Despite this, the emergency exit door alarm did not sound when the resident exited. The resident's care plan included interventions such as checking the WanderGuard's function every shift and ensuring it was worn at all times. However, the documentation of 15-minute safety checks was inconsistent, with the last check recorded at 4:23 A.M., nearly an hour before the resident was found missing. Interviews with staff revealed that the resident had been exit-seeking earlier in the night, but no administrative staff was notified of this behavior. The DON indicated that if the staff had been informed of the resident's exit-seeking behavior at 2:00 A.M., a 1:1 observation could have been implemented. The facility's policy required staff to notify the nurse on duty of any resident suspected of being an elopement risk, but this protocol was not followed. Additionally, the emergency exit door's alarm system was found to be functioning correctly during checks conducted after the incident.
Failure to Provide Written Notification for Transfer and Discharge
Penalty
Summary
The facility failed to ensure the written notification required for a transfer and discharge was provided to the resident's representative for a resident reviewed for hospitalization. The resident, diagnosed with hepatic encephalopathy, was sent to the hospital on two occasions. The clinical record lacked documentation of written notification of the Notice Transfer and Discharge forms being provided to the resident and the resident's representative. During an interview, the Director of Nursing (DON) indicated that the facility sent the Notice of Transfer and Discharge forms with the resident but did not provide the forms in writing to the resident's representative. The facility's policy did not indicate the requirement to send the Notice of Transfer and Discharge form to the resident and resident representative when the resident was transferred to the hospital.
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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 Vincennes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lodge Of The Wabash | 1 mi | ★★★★★ | 18 | 0 |
| Bridgepointe Health Campus | 1.2 mi | ★★★★★ | 5 | 0 |
| Aperion Care Vincennes | 6 mi | ★★★★★ | 24 | 0 |
| The Haven Of Bridgeport | 12.7 mi | ★★★★★ | 6 | 0 |
| Oak Village | 15.4 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.