Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

GENTLE CARE STRATEGIES

VINCENNES, IN · 60 certified beds · Last Life Safety survey April 24, 2025

CMS Certification Number 155519 · first certified April 1994

Ownership

Independently operated (no chain recorded by CMS) · For profit - Limited Liability company

  • Ownership changed May 1, 2022 (change of ownership)from GOOD SAMARITAN HOSPITAL
27
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
11
Inspection & testing records
Of the citations on file

Position within IN

27 citations — more than 81% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (April 2026 to June 2026), and past the point by which nine in ten IN facilities have been surveyed. This facility’s last Life Safety survey was April 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

6 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.

This facility27IN median15National median11
Citations on file over three years, compared
MeasureCitations
This facility27
Median facility in IN15
Median facility nationally11

Survey history

Citations at each Life Safety survey
92022-06122024-0362025-04
Citations at each Life Safety survey
Survey dateCitations
June 10, 20229
March 15, 202412
April 24, 20256

Most-cited tags

Most-cited tags at this facility
K-03533K-07122K-03452K-01002K-03552K-03241K-03461E-00371
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32025-04-24
K-0712Have simulated fire drills held at unexpected times.22025-04-24
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22025-04-24
K-0100Meet other general requirements.22025-04-24
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.22024-03-15
K-0324Provide properly protected cooking facilities.12024-03-15
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.12024-03-15
E-0037Establish staff and initial training requirements.12022-06-10

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 11
  • Emergency Preparedness Deficiencies 6
  • Miscellaneous Deficiencies 4
  • Construction Deficiencies 2
  • Other 4
Citations by CMS category
CategoryCitations
Smoke Deficiencies11
Emergency Preparedness Deficiencies6
Miscellaneous Deficiencies4
Construction Deficiencies2
Egress Deficiencies2
Services Deficiencies1
Gas, Vacuum, and Electrical Systems Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 24, 2025 — 6 citations

Citations issued on April 24, 2025
TagWhat the surveyor checksStatus
K-0100Meet other general requirements.Deficient, Provider has date of correction (May 27, 2025)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (May 27, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 30, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 23, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 27, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 30, 2025)

March 15, 2024 — 12 citations

Citations issued on March 15, 2024
TagWhat the surveyor checksStatus
K-0100Meet other general requirements.Deficient, Provider has date of correction (May 17, 2024)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (May 17, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (May 17, 2024)
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.Deficient, Provider has date of correction (May 17, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 17, 2024)
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.Deficient, Provider has date of correction (May 17, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 17, 2024)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (May 17, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (May 17, 2024)
K-0522Have an externally vented heating system.Deficient, Provider has date of correction (May 17, 2024)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (May 17, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 17, 2024)

June 10, 2022 — 9 citations

Citations issued on June 10, 2022
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (August 5, 2022)
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (August 5, 2022)
E-0029Develop a communication plan.Deficient, Provider has date of correction (August 5, 2022)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (August 5, 2022)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (August 5, 2022)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (August 5, 2022)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (August 5, 2022)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (August 5, 2022)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (August 5, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.