Gentle Care Strategies

In the surveyor’s words

From the most serious findings on record at Gentle Care Strategies, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 5 of 18 residents sampled. Two residents were on Aspirin (ASA), a resident was on oxygen, a resident self administered eye drops, and a resident kept a urinal on the beside table but did not have care plans for them. (Resident 36, Resident 50, Resident 112, Resident 54, Resident 29) Findings include: 1. On 4/23/25 at 10:39 A.M., Resident 36's clinical record was reviewed. […]

• No harm, potential for more than minimal, isolatedF657Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident's care plan was revised for 2 of 5 residents reviewed for unnecessary medications and 1 of 3 reviewed for Activities of Daily Living (ADL) decline. A resident's care plan was not reviewed or revised to remove areas of concern that were no longer relevant to the resident's care, i.e. antibiotic use, fracture care, and antipsychotic use. (Resident 112, Resident 46, Resident 12) Findings include: 1. On 4/23/25 at 11:17 A.M., Resident 112's clinical record was reviewed. Resident 112 was admitted on [DATE]. […]

• No harm, potential for more than minimal, isolatedF761Apr 24, 2025

  Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 2 medication carts observed. A medication cup with loose controlled substances was observed in a medication cart. (100 hall) (Resident 3, Resident 12, Resident 6) Finding includes: During an observation on 4/23/25 at 10:18 A.M., the medication cart on the 100 hall had 3 clear medication cups that included the following controlled substances: Resident 3--1 tramadol 50 milligram (mg) tablet Resident 12-- 1 Ativan 0.5 mg tablet Resident 6-- 1 hydrocodone-actaminophen 5-325 mg tablet During an interview on 4/16/25 at 10:25 A.M., the Director of Nursing (DON) indicated controlled substances should be stored under a double lock at all times. […]

• No harm, potential for more than minimal, isolatedF689Sep 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure adequate supervision and a secured environment was in place to prevent a resident with dementia from exiting the facility unsupervised. On 9/21/24, while on 15-minute checks, a resident was noticed to be missing at 5:20 A.M. Staff quickly located the resident outside the Hall 2 emergency exit door where the resident exited the facility and apparently fallen while unsupervised. (Resident C) Finding includes: A review of facility reported incidents on 9/30/24 at 11:15 A.M., included an IDOH (Indiana Department of Health) Reportable Incident form completed by the Facility Administrator, with an incident date of 9/21/24 at 5:30 A.M., indicated that staff was notified that Resident C was missing from her room at… […]

• No harm, potential for more than minimal, isolatedF623Mar 15, 2024

  Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident's representative for 1 of 1 residents reviewed for hospitalization . (Resident 4) Finding includes: On 3/15/24 at 11:00 a.m., Resident 4's clinical record was reviewed. The diagnosis included, but was not limited to, hepatic encephalopathy. Resident 4's progress notes indicated the resident was sent to the hospital on 1/11/24 and 1/29/24. The clinical record lacked documentation of written notification of the Notice Transfer and Discharge forms having been provided to the resident and the resident representative. […]