Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Lindsay Gardens Nursing & Rehabilitation during CMS and state inspections, most recent first.
Incomplete Wound Care Documentation and Incorrect EMR Order Entry: A resident with a sacrococcyx pressure ulcer and venous stasis ulcers to the bilateral toes and ankles had ordered wound treatments entered incorrectly in the EMR and not documented on the TAR. The ORR showed ordered wound care every shift, but the TAR had no documentation of the treatments. The LVN, DON, and ADON could not provide evidence that the wound care had been recorded after administration, and the DON stated the orders were entered incorrectly so they did not appear on the TAR.
A facility failed to develop, implement, and revise comprehensive CPs for three residents. One resident with CKD had a CCHO/Renal diet order and diet waiver, but the CP did not address renal diet noncompliance, risks, or documented efforts to honor preferences while following the therapeutic diet; staff also served alternate meals from an informal kitchen list not tied to policy. Another resident with dementia had inappropriate sexual verbalizations, profanity, and aggression toward staff, but only a general behavior CP was in place and no CP addressed sexual verbalization. A third resident’s CP called for continuous O2 at 2 L NC and daily/PRN SpO2 checks, but staff could not find an O2 order or recent SpO2 documentation, and the ADON stated the CP was not being implemented.
Missing Oxygen Orders and Incomplete O2 Saturation Monitoring: Two residents were observed receiving O2 without a physician order, including one resident with an empty tank attached to her wheelchair and another resident on continuous O2 by NC. For one resident, the MAR and order review showed pulse oximetry was ordered every shift, but no O2 saturation monitoring was documented and the task was marked as not completed.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week. Staff interviews showed inconsistent understanding of RN presence, and the Administrator stated the facility had not had an RN working on the floor consistently and relied on the DON for coverage. Time sheets for two RNs showed many days when no RN worked in the facility besides the DON.
A dietary aide did not follow the 3-compartment dishwashing process when she washed a food container and placed it directly into the sanitizer sink without rinsing it first. During lunch tray line service, another dietary employee wore gloves, put her hands in her pockets, touched her body and clothing, and continued handling meal service items without removing the gloves and washing her hands.
Failure to maintain infection control practices occurred when the facility had no documented WMP for water system risk assessment, monitoring, or control of Legionella and other waterborne bacteria, and when an LVN used the same syringe to administer Morphine Sulfate oral solution to a resident, reintroducing the used syringe into the clean medication container after it had been placed in the resident’s mouth. The IP and MD could not describe the facility’s water system risks, controls, or monitoring, and the DON and LVN acknowledged the syringe should have been disinfected or cleaned between uses.
A resident's urine collection bag was left uncovered and visible from the hallway, where it could be seen by other residents, staff, and visitors. An LVN stated the bag needed a cover for privacy, and the resident's ORR directed that the indwelling urinary catheter be kept in a privacy bag at all times.
Two residents were observed with video cameras in their rooms, and a monitor at the nurses station allowed staff to watch one resident lying in bed. The DON confirmed there were no consent forms, no IDT notes documenting consent, and no physician orders for video monitoring for either resident. One resident's CP did not include video monitoring, while the other resident's CP listed a baby monitor intervention. Facility policy required resident consent before surveillance equipment could be installed in a resident room.
A resident’s IDT care plan was not updated to reflect current renal status and care needs. The nephrology note documented AKI superimposed on CKD, acute renal failure, nutritional risk, good urinary output, and no edema, but the care plan still called for monitoring edema, daily weight gain over 2 lbs, and I&O monitoring. The DON stated the facility could not monitor daily weight gain because the resident was weighed monthly and that I&O’s were not being implemented because urinary output was not quantified.
Telephone orders for a resident's sacro-coccyx DTI were not reduced to writing or entered into the medical record, so the ordered daily barrier cream treatment was not on the TAR. An ADON stated she called the primary MD after the wound team recommended cleansing with NSS, patting dry, and applying barrier cream, but the orders were not documented as required by the facility's Telephone Orders policy.
Failure to provide appropriate foot care. A resident was observed with dry, flaky skin around the toes and on both feet, along with long, thick, untrimmed toenails. The resident said no one had cared for her feet and she had not seen a podiatrist. A CNA and an LVN both confirmed the poor condition of the resident’s feet, and the DON stated proper foot care had not been provided.
Improper HOB Positioning During Tube Feeding: A resident receiving Jevity 1.5 via G-tube was observed lying with the HOB below 30 degrees while the feeding was running at 60 ml/hr. A CNA and an LVN both noted the HOB should have been elevated, but the bed had no indicator to show the angle. The resident’s orders required the HOB to be kept at 45 degrees or greater, and the care plan and facility policy also called for HOB elevation during enteral feeding.
Improper Storage and Labeling of Outside Food: The facility failed to follow its policy for food brought in by family/visitors when outside food for a resident was stored in the employee breakroom refrigerator. An LVN observed a tied white plastic bag marked only with a room identifier, without the resident's name or a use-by date, and the DON stated the refrigerator used for resident food had no temperature monitoring. A DA also stated residents' outside food was not allowed in the kitchen refrigerators, while the facility policy required labeling with the resident's name, item, and use-by date and refrigerated storage at 41 degrees F or lower.
A resident admitted with a left arm cast did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. Review of clinical records and interview with the DON confirmed the absence of a care plan addressing the cast, despite documentation of the cast at admission.
A resident admitted with a left arm cast did not receive a required follow-up appointment with an orthopedic doctor. Despite documentation indicating the need for follow-up, an LVN reported insurance issues and difficulty locating a provider, and the SSD did not take further action or was unaware of the need. No orthopedic referral was made, contrary to facility policy requiring social services to coordinate such referrals.
A facility failed to document the removal of a lap tray restraint every two hours for a resident at high fall risk. Despite staff claims that the tray was removed as required, no documentation was found in the resident's records. The facility's policy mandates documentation of restraint removal to ensure opportunities for motion and exercise.
The facility exceeded the acceptable medication error rate, with two errors out of 35 opportunities, resulting in a 5.71% error rate. Two residents with type two diabetes and severe cognitive impairment were affected when an LVN failed to follow proper procedures for administering Humalog insulin, as per the manufacturer's instructions. The LVN acknowledged the error, and both the DON and Administrator emphasized the importance of adhering to physician orders.
A resident with a history of renal dialysis and chronic kidney disease was inaccurately assessed in the MDS, indicating no dialysis during the assessment period despite having active orders for hemodialysis. The MDS Coordinator and DON confirmed the error, highlighting the importance of accurate MDS coding for care and billing.
A resident was not referred for a Level II PASARR assessment after being newly diagnosed with schizophrenia. Initially admitted with a diagnosis of muscle wasting, the resident's PASARR Level I screening showed no serious mental illness. However, a psychologist later diagnosed schizoaffective disorder, and the DON failed to make the necessary referral, being unaware of the requirement. The administrator expected accurate and timely PASARR documentation.
The facility failed to administer insulin and metoprolol as ordered for two residents, leading to deficiencies. One resident with diabetes did not receive Lantus insulin due to misinterpretation of blood glucose levels, while another resident's metoprolol and insulin were withheld based on nursing judgment rather than physician orders. Inconsistent documentation of communications with the physician contributed to the issue.
A facility failed to reorder insulin timely for a resident with diabetes, resulting in a missed dose. The resident, with severe cognitive impairment, required daily insulin injections. Facility policy required medications to be reordered three to four days in advance, but the insulin was not reordered in time. An LVN found the insulin missing on her shift, and the DON confirmed the expectation to reorder within two to three days of running out.
Incomplete Wound Care Documentation and Incorrect EMR Order Entry
Penalty
Summary
The facility failed to follow its policy and procedure for wound care documentation when physician-ordered treatments were not entered correctly in the EMR and were not documented on the TAR for one sampled resident. The resident had a pressure ulcer to the sacrococcyx and venous stasis ulcers to the bilateral toes and bilateral ankles, and the care plan directed staff to administer the ordered treatments. The ORR showed orders for coccyx wound care with dermal wound spray, Medihoney, and foam dressing every shift, as well as treatment to the bilateral toes and ankles with dermal wound spray and betadine every shift. During record review, the TAR contained no documented treatments for the coccyx, bilateral toes, or bilateral ankles. The LVN, DON, and ADON were unable to provide documentation showing the wound treatments had been recorded after administration. The DON stated the physician orders were entered incorrectly and were not indicated to appear on the TAR when administered, and the LVN who entered the treatment orders stated they were entered incorrectly and did not appear on the TAR for administration. The facility policy required wound care documentation to include the type of wound care given, the date and time it was given, and the name and title of the individual performing it.
Incomplete and Unimplemented Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and revise comprehensive care plans for three sampled residents. For one resident with chronic kidney disease, a CCHO/Renal diet order, and a signed diet waiver, the meal tray card reflected specific food preferences, but the care plan did not document noncompliance with the renal portion of the diet, the risks of refusing the ordered therapeutic diet, or specific attempts to offer alternative approaches that would support the resident’s preferences while following the diet order as closely as possible. The Director of Nursing stated there was no documentation of further discussion with the resident about the diet waiver or his dietary wishes since 2023, despite significant changes in condition in 2025 including a heart attack and acute kidney injury on top of chronic kidney disease. During observation, the resident was served an alternate lunch meal that differed from the planned renal/CCHO diet. The Dietary Manager Assistant stated the facility did not have meal alternatives available that had been evaluated or modified for therapeutic diets, and that dietary staff were instructed to serve the available meal alternative whenever the resident requested it because he had a signed contract/form. The posted list of alternate meals was kept on a board in the Dietary Manager Assistant’s office and was not incorporated into a facility policy or procedure. The facility’s policy stated residents refusing a meal should be offered a food substitution in accordance with the resident’s diet order, and the care plan policy required measurable objectives, time frames, and services derived from the resident’s assessment and preferences. For another resident with moderate depressive disorder and dementia, staff reported inappropriate verbal behavior toward staff, including sexualized language, profanity, and aggression during care. The DON stated the resident had only a care plan for negative behaviors and that there was no care plan for sexual verbalization, despite the resident’s inappropriate verbalizations to female staff. For a third resident, the care plan indicated continuous oxygen use, oxygen at 2 liters via nasal cannula, and daily and as-needed oxygen saturation monitoring, but the Assistant Director of Nurses could not find an oxygen order, could not find recent oxygen saturation results, and stated the last documented oxygen saturation was from several months earlier. The ADON stated the oxygen care plan was not being implemented and should have been.
Missing Oxygen Orders and Incomplete O2 Saturation Monitoring
Penalty
Summary
The facility failed to obtain a physician's order before providing oxygen to two sampled residents. Resident 36 was observed in the dining room on a nasal cannula attached to an empty oxygen tank on her wheelchair, and LVN 6 stated the tank was empty and should have been changed before she was brought to the dining room. During record review, the ADON could not find a physician order for oxygen for Resident 36 and stated the resident was receiving oxygen and should have had an order before it was administered. Resident 84 was observed in her room receiving oxygen at 3 liters via nasal cannula, and she stated she had been wearing continuous oxygen for years. Review of Resident 84's physician orders showed no order for oxygen, and both LVN 8 and the DON stated she did not have a physician order for continuous oxygen use and should have had one. The facility also failed to follow the physician's order for Resident 84's oxygen saturation monitoring. Resident 84's Order Review Report dated 7/14/25 directed staff to monitor pulse oximetry every shift and administer oxygen via nasal cannula if oxygen was less than 90%. During review of the January 2026 MAR, no oxygen saturation monitoring was documented, and LVN 8 stated oxygen saturation levels should have been documented each shift. During review of the December 2025 MAR, the task to monitor pulse oximetry every shift was marked with an X in each box from 12/1/25 through 12/31/25, and the DON stated the X indicated the task was not completed. Resident 84 stated staff checked her vital signs once per night and that she thought her oxygen levels needed to be checked more often.
RN Coverage Not Maintained Daily
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was scheduled to work at least eight consecutive hours a day, seven days per week. During interviews, a CNA stated there was an RN on weekends but was unsure about weekday coverage, while an LVN stated the weekday RN was the DON and another LVN stated an RN worked daily. The Administrator later stated the facility had not had an RN working on the floor consistently since June 2025 and that the facility used the DON for coverage. During a concurrent interview and record review, time sheets for two RNs were reviewed and showed multiple dates from 10/1/25 through 1/1/26 when no RN worked in the facility. The HR/Payroll Manager stated there were multiple days per week when there was no RN working 8 consecutive hours besides the DON. The Administrator also stated the 99-bed facility averaged over 60 residents and did not have an RN to work daily on weekdays, and that an additional RN besides the DON should have been available.
Food Handling and Hand Hygiene Lapses During Meal Service
Penalty
Summary
The facility failed to ensure that its 3-compartment manual dishwashing procedure was followed when one dietary aide washed a large mixing food container in the first sink of the 3-compartment sink and then placed it directly into the third compartment containing sanitizing solution without rinsing it in the second compartment. The dietary aide stated she did not use the second compartment because there was no foam on the container. The Dietary Manager Assistant later stated the container should have been rinsed in the second compartment before sanitizing, and the facility policy and the FDA Food Code both described the second compartment as the rinsing step after washing. The facility also failed to ensure proper hand hygiene during lunch tray line meal service when another dietary employee, while wearing blue gloves, placed her hands in her pants pockets, removed her gloved hands from her pockets, picked up a plate cover for residents' lunch meal service, and then crossed her arms and touched her skin and shirt without removing the gloves to wash her hands and put on a clean pair of gloves. The dietary employee stated she should not have placed her hands, even with gloves, in her pockets or touched her body and said it was unsanitary. The Dietary Manager Assistant stated the employee should have removed her gloves and washed her hands, and the facility hand washing policy and FDA Food Code required hand cleaning before working with food and to prevent cross contamination when changing tasks.
Failure to Maintain Infection Control Practices
Penalty
Summary
The facility failed to implement an infection prevention and control program when a Water Management Program (WMP) was not in place for 32 of 32 sampled residents. During a concurrent interview and record review, the Infection Preventionist stated the facility did not have documentation of a WMP and could not verbalize areas within the facility that had been assessed for risk, measures used to mitigate risk, acceptable control limits and parameters, or how those limits and parameters were monitored. The Maintenance Director also stated he had not received training on the WMP or prevention of Legionella growth and could not identify areas of the facility at risk for bacteria growth in the water system, measures used to mitigate and monitor risk, control limits, parameters, or a diagram or documentation describing the facility water system and areas of concern. The facility policy and procedure for Legionella Water Management Program, dated September 2022, was reviewed and indicated the program should include a detailed description and diagram of the water system, identification of areas that could encourage growth and spread of Legionella or other waterborne bacteria, identification of situations that can lead to Legionella growth, specific measures used to control introduction and spread, acceptable control limits or parameters, a diagram of where control measures are applied, a system to monitor control limits and effectiveness, a plan for when limits are not met, and documentation of the program. A CDC Legionella Control Toolkit was also reviewed and described key factors affecting Legionella growth in potable water systems, including sediment, biofilm, temperature, water age, and disinfectant residuals, along with monitoring and maintenance practices for water system components. The facility also failed to use aseptic technique during medication administration for one sampled resident receiving Morphine Sulfate oral solution. During observation, an LVN administered the medication under the resident’s tongue, then used the same syringe to draw more medication from the clean medication container after it had been placed in the resident’s mouth, and repeated this process before placing the used syringe in a plastic bag. During interview, the LVN stated she should have disinfected the syringe between placing it back into the medication container, and the DON stated the syringe should have been cleaned after it was put into the resident’s mouth. The facility policy on administering medications stated staff shall follow established infection control procedures, including antiseptic technique, for medication administration.
Uncovered urine collection bag visible from hallway
Penalty
Summary
The facility failed to ensure dignified care for one sampled resident when Resident 7's urine collection bag was left uncovered and visible to other residents, staff, and visitors. During observation, the bag containing yellow liquid was hanging on the side of Resident 7's bed and could be seen from the hallway. When interviewed at the time of observation, an LVN stated the collection bag needed a cover to provide privacy for Resident 7. The resident's ORR stated that the indwelling urinary catheter was to be kept in a privacy bag and that the catheter leg strap was to be on at all times. The facility's Resident Rights policy stated that every effort would be made to assist each resident in exercising rights and to ensure the resident is always treated with respect, kindness, and dignity.
Unauthorized Video Surveillance in Resident Rooms
Penalty
Summary
The facility failed to ensure privacy and confidentiality for two sampled residents when 24-hour video surveillance was used in their rooms without written consent. During observation, a round-shaped video camera was seen hanging on the wall at the foot of one resident's bed, and a monitor at the nurses station showed that resident lying in bed. Staff stated the monitor screen was kept at the nurses station so staff could observe the resident. For the second resident, a small round video camera was observed on the bedside table next to the bed, and staff stated both residents had video cameras in their rooms to monitor them and help prevent falls. Record review and interviews with the DON showed there was no consent form for video surveillance for either resident, no IDT notes documenting consent, and no physician order for video monitoring for either resident. The DON also stated that one resident's care plan did not indicate video monitoring as an intervention, while the other resident's care plan listed a baby monitor intervention that had been initiated previously. The facility policy stated surveillance equipment may not be installed in a resident room or treatment area unless approved by the Administrator and with the resident's consent.
Care Plan Not Updated to Match Resident’s Current Renal Status
Penalty
Summary
The facility failed to ensure that Resident 61’s interdisciplinary team comprehensive plan of care was updated and revised to reflect the resident’s current health status, care needs, and interventions. During record review, the resident’s nephrology progress note documented acute kidney injury superimposed on chronic kidney disease, acute renal failure, nutritional risk, good urinary output, and no edema or joint swelling. However, the resident’s comprehensive care plan for renal failure, initiated on 6/27/25, still included interventions to monitor and report edema and weight gain of over 2 lbs in a day, even though the DON stated the facility had no way to monitor daily weight gain because the resident was weighed only once a month. The resident’s comprehensive care plan for nutritional risk, also initiated on 6/27/25, included an intervention to monitor intake and output. During interview and record review, the DON stated the resident did not have an order for I&O’s and nursing staff were not implementing I&O monitoring because urinary output was not being quantified. The DON stated this care plan also needed to be updated and revised. The facility policy stated the interdisciplinary team should review and update the care plan when there is a significant change in condition, upon readmission from a hospital stay, and at least quarterly with the required quarterly MDS assessment.
Telephone orders for wound care were not documented
Penalty
Summary
The facility failed to follow its policy and procedure titled, Telephone Orders, when a physician's telephone orders for Resident 10 were not recorded in the resident's medical record. Resident 10 stated he had an area on his buttocks that occasionally burns. During record review, a progress note dated 12/18/25 showed that Physician 1 completed a weekly wound assessment and identified a sacro-coccyx DTI, with treatment recommendations to cleanse with NSS, pat dry, and apply barrier cream daily. The ADON stated that Physician 2 and the IDT were notified of the recommendations and agreed with the plan of care. During review of the TAR and ORR, there were no treatment records for the recommended daily barrier cream, and Resident 10 did not have any physician orders for barrier cream to the sacro-coccyx area. The ADON stated she had called the resident's primary doctor to inform him of Physician 1's recommendations and had received telephone orders, but she did not document the orders in the resident's medical record. The facility's Telephone Orders policy required verbal telephone orders to be reduced to writing, recorded in the resident's medical record, and signed and dated by the person transcribing the information.
Failure to Provide Appropriate Foot Care
Penalty
Summary
Provide appropriate foot care. The facility failed to ensure one of 33 sampled residents, Resident 5, received treatment and services to both feet. During a concurrent observation and interview, Resident 5’s feet were exposed and showed dry, flaky skin around the toes and on the top and bottom of both feet, and the toenails were long, thick, and untrimmed. Resident 5 stated she had not seen a podiatrist and that no one had taken care of her feet. CNA 2 also observed that the toenails were very thick and yellow and green with dry, scaly skin around the toes and feet. During a separate concurrent observation and interview, LVN 2 observed Resident 5’s feet and stated the resident had thick, long nails on both feet and flaky skin around the feet and toes. LVN 2 stated the expectation would be for lotion around the feet, for the resident to see a podiatrist, and to contact hospice, and stated the resident’s skin and nails had not been attended to as needed. The DON later stated Resident 5 had not been provided proper foot care and that staff are to alert licensed staff even if a resident is receiving hospice care, but this had not been done. The facility policy stated residents will receive appropriate foot care and treatment, and residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals.
Improper HOB Positioning During Tube Feeding
Penalty
Summary
The facility failed to ensure that Resident 68’s head of bed was elevated during a G-tube feeding. During an observation, Resident 68 was lying in bed with Jevity 1.5 running at 60 ml per hour, and the head of bed was positioned below a 30-degree angle, approximately 15 degrees. The bed did not have a device to indicate the angle of the head of bed. A CNA and an LVN both observed the resident during the feeding and stated the head of bed should have been elevated, but neither could determine the exact angle because there was no indicator on the bed. Resident 68 stated that her head of bed is usually up, but it was not up at the time of the observation. The resident’s order review report directed that tube feeding run 17 hours per day at 60 ml per hour with 45 ml per hour water flush, and another order stated to keep the head of bed at 45 degrees or greater at all times. The care plan identified the resident as at risk for enteral nutrition complications related to aspiration pneumonia and included elevating the head of bed to at least 30 degrees. The facility policy on enteral feedings also stated that the head of bed should be elevated at least 30 degrees during tube feeding and for at least one hour after feeding.
Improper Storage and Labeling of Outside Food
Penalty
Summary
The facility failed to ensure its policy and procedure titled, Foods Brought by Family/Visitors, provided sufficient guidance on safe refrigerated food storage and was followed for labeling resident outside food brought into the facility. During an interview and observation in the employee breakroom refrigerator, LVN 9 identified a white plastic bag tied with a container inside and marked only with "101A". LVN 9 stated the bag contained outside food for the resident in room 101A, but it did not have the resident's name or a use-by date. LVN 9 also observed a thermometer in the refrigerator and stated the temperature was 24 degrees F, and he did not know whether the refrigerator temperature was monitored to identify when it might be out of range. During a concurrent observation, DA 3 saw the same white plastic bag labeled "101A" in the employee breakroom refrigerator and stated residents' food brought in from family or visitors was not allowed to be stored in the kitchen refrigerators. The DON later stated there was no temperature monitoring of the employee breakroom refrigerator used to store resident food brought in from outside the facility and that there should have been. Review of the facility's policy stated food brought by family or visitors left for later consumption is to be labeled with the resident's name, the item, and the use-by date, and the refrigerated storage procedure stated refrigerators should be 41 degrees F or lower.
Failure to Develop Baseline Care Plan for Resident with Arm Cast
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted with a left arm cast. Review of the resident's progress notes confirmed the presence of the cast at admission, but no care plan addressing the cast was found in the clinical record. During an interview and record review, the DON confirmed the absence of a care plan for the resident's left arm cast. The facility's policy requires a baseline plan of care to be developed within 48 hours to address immediate health and safety needs, but this was not completed for the resident in question.
Failure to Arrange Orthopedic Follow-Up for Resident with Arm Cast
Penalty
Summary
The facility failed to ensure that a follow-up appointment with an orthopedic doctor was made for a resident who was admitted with a left arm cast. According to the Interdisciplinary Team note, the resident required orthopedic follow-up, but this was not arranged. During interviews, a Licensed Vocational Nurse stated that the resident had insurance issues and difficulty finding an orthopedic doctor, and that the Social Service Designee (SSD) was aware of the situation but did not take further action. The SSD later stated she was not aware that the resident required orthopedic follow-up, and no appointment was made. Review of facility policy indicated that social services are responsible for coordinating most resident referrals with outside agencies.
Failure to Document Restraint Removal
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the documentation of restraint removal for a resident. During an observation, it was noted that the resident was seated in a Geri chair with a lap tray, which was intended for comfort and safety due to the resident's high fall risk. The facility's policy required that the lap tray be removed every two hours to allow for motion and exercise, and this action should have been documented. However, interviews with staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, revealed that while the lap tray was reportedly removed every two hours, the staff did not document these removals. Further review of the resident's clinical records by the Director of Nursing confirmed the absence of documentation regarding the removal of the lap tray. The facility's policy on the use of restraints, dated April 2017, stipulated that residents in restraints should be provided with opportunities for motion and exercise for at least ten minutes every two hours, and this should be documented. The lack of documentation for the removal of the lap tray every two hours constituted a failure to meet the professional standards of quality care as outlined in the facility's policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two errors out of 35 opportunities, resulting in a 5.71% error rate. The errors involved two residents, both with a history of type two diabetes mellitus and severe cognitive impairment. The facility's policy required medications to be administered safely and as prescribed, but during observations, it was noted that the Licensed Vocational Nurse (LVN) did not adhere to the manufacturer's instructions for administering Humalog insulin. Specifically, the LVN failed to leave the syringe in place for five seconds after injection, which is necessary to ensure the full dose is delivered. Resident #46, admitted in May 2021, had an order for Humalog insulin based on a sliding scale, which was not properly administered when the resident's blood glucose level was 210 mg/dL. Similarly, Resident #77, admitted in March 2023, also had a sliding scale insulin order, and the LVN did not follow the correct procedure when the resident's blood glucose level was 208 mg/dL. The LVN acknowledged awareness of the correct procedure and recognized the error, having discussed it with the Director of Nursing (DON). The DON and the Administrator both expressed expectations that medications be administered according to physician orders and in the correct manner.
Inaccurate MDS Assessment for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically Resident #57, who was one of the 21 sampled residents. The facility's policy required that any person completing any portion of the MDS assessment sign it to certify its accuracy, and that the information captured should reflect the resident's status during the observation period. Resident #57, who had a medical history of dependence on renal dialysis and chronic kidney disease, was admitted to the facility and had an active order for hemodialysis three times a week. However, a quarterly MDS assessment indicated that the resident did not receive dialysis during the assessment period, which was incorrect. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the MDS assessment for Resident #57 was coded incorrectly. The MDS Coordinator acknowledged the error, and the DON confirmed the inaccuracy, emphasizing the importance of MDS accuracy for driving care and billing. The Administrator also stated the expectation for MDS assessments to accurately reflect the resident's current status. The error was assumed to be a mistake, as prior assessments for the resident were coded accurately.
Failure to Refer Resident for Level II PASARR Assessment
Penalty
Summary
The facility failed to ensure that a resident was referred for a Level II Preadmission Screening and Resident Review (PASARR) assessment after being newly diagnosed with a serious mental illness. The facility's policy required the admitting nurse to notify the social services department when a resident was identified with a possible mental disorder, and the social worker was responsible for making referrals to the appropriate state-designated authority. However, the Director of Nursing (DON), who was responsible for PASARR screenings, did not make a referral for the resident after the new diagnosis of schizophrenia was made post-admission. The resident was admitted with a primary diagnosis of muscle wasting and atrophy, and the initial PASARR Level I screening indicated no serious mental illness, thus not requiring a Level II screening. However, a psychologist consultation shortly after admission revealed symptoms of schizoaffective disorder, leading to a new diagnosis of schizophrenia. Despite this, the DON did not submit a referral for a Level II PASARR screening, as she was unaware of the requirement. The facility administrator expected PASARR documents to be completed accurately and timely, including resubmission for review upon new diagnoses.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to follow physician's orders for two residents regarding the administration of medications, specifically insulin and metoprolol. Resident #33, who had a diagnosis of type 2 diabetes mellitus and severe cognitive impairment, did not receive their prescribed Lantus insulin on multiple occasions. On 05/17/2024, the insulin was withheld by LVN #1 despite the resident's blood glucose level being 133 mg/dL, which was above the threshold for holding the medication. Additionally, on 07/01/2024, the insulin was not administered due to it being on order, as noted by LVN #2. Resident #84, with a history of type 2 diabetes mellitus and essential hypertension, also experienced issues with medication administration. The resident's metoprolol was held on several occasions by LVN #2 due to blood pressure readings that were close to, but not outside, the physician-ordered parameters. The resident's glargine insulin was also withheld on multiple occasions without physician-ordered parameters to do so. LVN #2 admitted to holding the insulin based on her judgment and the resident's eating habits, but documentation of these decisions and communications with the physician was inconsistent. Interviews with the nursing staff and the Director of Nursing revealed discrepancies in the understanding and execution of medication orders. The DON emphasized that medications should be administered as ordered unless there is a clear directive from the physician to hold them. The physician, MD #7, acknowledged frequent communication with the nursing staff regarding medication administration but noted that these interactions were not consistently documented. The facility's failure to adhere to medication orders and properly document communications with the physician led to the identified deficiencies.
Failure to Reorder Insulin Timely for Diabetic Resident
Penalty
Summary
The facility failed to provide routine pharmaceutical services to ensure medications were available for administration to a resident with diabetes. The resident, who had severe cognitive impairment, was admitted with a diagnosis of type 2 diabetes mellitus and required daily insulin injections. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply. However, the resident's Lantus insulin was not reordered in time, resulting in a missed dose on July 1, 2024, as documented by a Licensed Vocational Nurse (LVN). The LVN stated that upon arriving for her shift on July 1, 2024, she found that the resident did not have any insulin, and the morning nurse had already placed an order for the medication. The Director of Nursing (DON) confirmed that insulin should be reordered within two to three days of running out, and ideally, it should have been reordered before the last dose was administered. The facility's failure to reorder the insulin in a timely manner led to the resident missing a scheduled dose, which was a deviation from the facility's policy and expectations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 139 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lindsay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Walk Care Center | 10.3 mi | ★★★★★ | 18 | 0 |
| Sequoia Transitional Care | 10.5 mi | ★★★★★ | 12 | 0 |
| Sierra View Medical Center | 10.7 mi | ★★★★★ | 1 | 0 |
| Sierra Valley Rehab Center | 11 mi | ★★★★★ | 0 | 0 |
| Gateway Post Acute | 11.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.