Cycle 1
Health 2025-04-24 · Fire 2025-04-24
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Vincennes, IN
Gentle Care Strategies
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1202 S 16th St, Vincennes, IN
(812) 882-8292
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
9,573
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.49% · Performance 22.81% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.90
Baseline 8.39% · Performance 7.57% · Measure score 1.90 · Achievement 0.87 · Improvement 1.90
Total nurse turnover
5.79
Performance 40.00% · Measure score 5.79 · Achievement 5.79 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.60
Baseline 4.62 hours · Performance 3.53 hours · Measure score 1.60 · Achievement 1.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.8% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 9.57% · Lower 95% interval 7.24% |
| Discharge to community | 47.57% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 48.19% · Lower 95% interval 38.36% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 86 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 22 · Denominator 66 |
| Discharge mobility score | 34.85% |
50.94%
16.1 pts worse
|
Numerator 23 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 2 · Denominator 86 · Adjusted rate 1.5% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 7.41% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 3.08% |
8.2%
5.1 pts worse
|
Numerator 2 · Denominator 65 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 34.85% |
56.45%
21.6 pts worse
|
Numerator 23 · Denominator 66 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 32.5% |
25.2%
7.3 pts better
|
Numerator 13 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.8%
2.7 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 33.7% |
24.6%
9.1 pts worse
|
11.4%
22.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.3% · Q2 18.6% · Q3 34.1% · Q4 32.6% · 4Q avg 33.7% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.6%
1.2 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.3% · Q3 2.4% · Q4 2.2% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.4% |
23.5%
6.9 pts worse
|
19.6%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 30.0% · Q3 34.9% · Q4 29.2% · 4Q avg 30.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
14.8%
3.7 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 11.1% · Q3 11.8% · Q4 13.5% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.6% |
13.3%
0.7 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.6% · Q3 11.3% · Q4 22.1% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
11.7%
2.6 pts worse
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 10.0% · Q3 9.3% · Q4 22.9% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.2%
0.6 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · Q4 2.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
24.2%
1.9 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 21.3% · Q3 26.1% · Q4 29.1% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
4.1%
3.6 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
81.6%
17.5 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 97.9% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
10.5%
2.4 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 7.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.3%
1.2 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
22.4%
1.9 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 19.6% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-06-10 · Fire 2022-06-10
2 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-04-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-04-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
C · Minimal harm
2025-04-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-30
F · Potential for more than minimal harm
2024-03-15
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-03-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-03-15
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-03-15
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-05-17
F · Potential for more than minimal harm
2022-06-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-08-05
F · Potential for more than minimal harm
2022-06-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-05
F · Potential for more than minimal harm
2022-06-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-05
F · Potential for more than minimal harm
2022-06-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-06-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-05
C · Minimal harm
2022-06-10
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-08-05
C · Minimal harm
2022-06-10
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-08-05
C · Minimal harm
2022-06-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-08-05
C · Minimal harm
2022-06-10
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-30
D · Potential for more than minimal harm
2024-09-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-03-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-28
D · Potential for more than minimal harm
2022-06-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-12
Penalties and ownership
What sits behind the stars
Ownership
Pulaski Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Barry, Thomas
Corporate Officer · Individual
Blue, Stacy
Contracted Managing Employee · Individual
Malott, Gregg
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Lodge Of The Wabash
Vincennes, IN
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Bridgepointe Health Campus
Vincennes, IN
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Aperion Care Vincennes
Vincennes, IN
1-star overall rating with 1-star inspections with Special Focus status with 23 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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