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 Lindsay Nursing & Rehab during CMS and state inspections, most recent first.
A resident with intact cognition, independent ADLs, COPD, respiratory failure, and PRN oxygen orders had multiple small portable oxygen cylinders stored unsecured on the floor of their closet, despite a facility policy requiring cylinders to be secured in a designated locked storage area and routinely checked. The care plan included use of a portable oxygen apparatus but lacked interventions addressing the resident’s practice of bringing in and storing portable cylinders from a family member’s home. Staff interviews revealed that a CNA knew cylinders should only be kept in a locked oxygen room, while a housekeeper had seen cylinders in the closet but did not know they were prohibited, and the DON acknowledged prior removals of cylinders from the room without established interventions to prevent recurrence.
A resident with COPD, intact cognition, and PRN oxygen orders was found to have numerous small portable oxygen cylinders stored in a closet, some standing and some tipped over on the floor, with at least two cylinders confirmed full. The resident reported bringing these cylinders from a family member’s home because the facility did not supply that type of portable oxygen. Although the resident’s care plan noted oxygen therapy and provision of a portable oxygen apparatus, it lacked interventions addressing the resident’s repeated unsafe storage of portable oxygen cylinders, despite the DON acknowledging the cylinders had been removed from the room several times for safety and that such interventions should have been included on the care plan.
A cognitively intact resident with paraplegia and an indwelling urinary catheter reported that when they approached an RN to discuss concerns about their catheter bag, the RN became angry, stated they did not care, and directed the resident to speak with someone else, causing the resident embarrassment and prompting them to return to their room. The facility’s abuse prevention policy required protection of residents from abuse by anyone, yet interviews and a grievance investigation confirmed that the RN had been verbally aggressive, including hollering and cursing, resulting in a substantiated finding of verbal abuse.
A cognitively intact resident with paraplegia and an indwelling catheter reported that an RN became angry when approached about a catheter bag and responded with profane, dismissive language, which was later substantiated as verbal abuse. The resident informed a CMA about the incident that evening, but the CMA did not immediately notify the administrator, honoring the resident’s request to self-report the next morning. The administrator was not informed until the following day and then had the resident complete a grievance form, after which the allegation was faxed to the state agency, resulting in the allegation not being reported within the required 2-hour timeframe.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised on two occasions, including being found walking on a highway, due to the facility's failure to identify elopement risk and implement appropriate supervision and interventions. Staff acknowledged that the resident's behaviors warranted earlier preventive measures, but these were not put in place until after the incidents occurred.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to three residents reviewed for beneficiary notification. The DON reported that no SNF ABN form was provided to these residents or their representatives. An RN stated that the SNF ABN form was previously included in the resident admission packet but had been removed at some point, and she was unaware of when this occurred.
A resident with Alzheimer's and a history of wandering eloped from the facility and was found by the local fire department. Despite being identified as at risk for elopement, the facility did not implement additional preventive measures after the incident. Staff were aware of the resident's wandering behavior, but no specific interventions were added to prevent future elopements.
A resident's grievance about a staff member's rudeness was not fully addressed by the facility, and the resident did not receive a requested written summary of the grievance. The facility's grievance policy required providing a written summary upon request, but the administrator and activity manager did not comply, believing it was an internal document. A corporate consultant confirmed residents are entitled to a copy of their grievances.
A resident with schizophrenia and other conditions was involved in an altercation with a staff member, leading to an abuse allegation. The facility failed to conduct a thorough investigation, as required by its policy, by not obtaining staff statements, notifying the DON, or reporting the incident to the police. The administrator relied on a single witness, and the ADON was unaware of the incident until days later.
A resident with a history of brain injury and dementia repeatedly eloped from the facility without supervision, despite being at risk. The facility lacked a comprehensive care plan and failed to report incidents, leading to multiple unsupervised departures and police involvement. Staff were unaware of the need for incident reporting, contributing to ongoing safety risks.
The facility allowed the DON to work as a charge nurse when the resident census exceeded 60, contrary to policy. Records and interviews confirmed the DON assumed charge nurse duties on several occasions with a census ranging from 61 to 72 residents. Staffing sheets and interviews with the DON and a corporate consultant corroborated these findings.
A facility failed to provide a resident with written notification of the bed hold policy upon transfer to a hospital. The resident, with conditions including hypertension and diabetes, was transferred for further evaluation and later admitted to another LTC facility. The facility's staff, including the BOM and ADON, were unaware of the bed hold policy, and the Administrator admitted that written notification should have been provided.
Unsecured Portable Oxygen Cylinders Stored in Resident Closet
Penalty
Summary
The facility failed to ensure safe storage of portable oxygen cylinders in accordance with its Oxygen Storage and Safety policy. The policy required full cylinders to be stored in a designated, well-ventilated area, empty cylinders to be stored separately and labeled as empty, and oxygen in resident rooms to be secured to prevent tipping, with routine checks to ensure proper storage and safety. For one resident with intact cognition, independent in activities of daily living, and receiving oxygen therapy for COPD and respiratory failure, the care plan included provision of a portable oxygen apparatus but did not include any interventions addressing unsafe storage of portable oxygen cylinders brought into the facility. The resident’s medical record contained no documentation that the facility checked the resident’s room for safe oxygen storage. During observation, surveyors found approximately 25 small portable oxygen cylinders for an over-the-shoulder carrier bag stored in the resident’s closet, standing upright and tipped over on the floor, and unsecured. Subsequent checking by the DON of three of these cylinders revealed that two were full. The resident reported that the facility would not supply the small portable cylinders, that they brought the cylinders from a family member’s home, and that only empty cylinders were stored in the closet. A CNA stated that oxygen cylinders were supposed to be stored in a locked room designated for oxygen and not in residents’ rooms. A housekeeper reported having seen oxygen cylinders in the resident’s closet while hanging clothes but was unaware they were not allowed there. The DON stated that oxygen cylinders were to be stored secured in a rack in a locked closet, acknowledged prior removal of cylinders from this resident’s room several times for safety, and was not aware of what interventions had been implemented to prevent the resident from continuing to store cylinders in the closet.
Failure to Update Care Plan for Safe Storage of Portable Oxygen Cylinders
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to update and individualize a resident’s care plan with interventions addressing unsafe storage of portable oxygen cylinders. Observation of the resident’s room showed 25 small oxygen cylinders stored in the closet, some standing and some tipped over on the floor, with subsequent checking by the DON revealing at least two cylinders were full. The resident had an annual assessment indicating intact cognition (BIMS 15), independence with ADLs, a diagnosis of COPD, and receipt of oxygen therapy. A physician’s order directed oxygen at 2 L/min via nasal cannula as needed for a history of respiratory failure. The existing care plan documented that the resident had oxygen therapy and was to be provided with a portable oxygen apparatus, but it did not include any interventions related to the resident’s practice of storing portable oxygen cylinders in the closet. The facility’s policy on comprehensive person-centered care plans stated that assessments are ongoing and care plans are to be revised as residents’ conditions or information about them change. The resident reported that the facility would not supply the small portable oxygen cylinders used in an over-the-shoulder carrier bag and that these cylinders were brought in from a family member’s home. CNA staff stated that no residents stored portable oxygen cylinders unsecured in their rooms or closets. The DON acknowledged that portable oxygen cylinders had been removed from this resident’s room several times for safety and that they were not aware of what interventions had been implemented to prevent the resident from storing cylinders in the closet. The DON further stated that interventions to ensure the resident was not storing oxygen cylinders unsecured should have been included on the care plan, and the administrator stated they had been unaware of the cylinders stored in the closet.
Failure to Protect a Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member. A cognitively intact resident with paraplegia, who was largely independent with ADLs and had an indwelling urinary catheter, approached an RN to discuss concerns about their catheter bag. According to a grievance form, when the resident attempted to discuss the catheter issue, the RN appeared angry and responded, "I don't want any part of that. I don't give a damn. Go talk to [name removed] about it." The resident reported feeling embarrassed by this interaction and returned to their room. The facility’s Abuse Prevention Program policy stated that administration would protect residents from abuse by anyone, including facility staff. Despite this policy, the resident’s grievance and subsequent investigation documented that the RN was verbally aggressive toward the resident. Staff interviews corroborated the resident’s account, including a CMA who reported that the resident told them later that day about the RN hollering and cursing at them. The investigation concluded that verbal abuse had occurred between the RN and the resident.
Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state survey agency within the required 2-hour timeframe. The facility’s Abuse Prevention Program policy required allegations of abuse to be investigated and reported within federal timeframes. A cognitively intact resident with paraplegia, an indwelling catheter, and independence with most ADLs reported that a registered nurse became angry when approached about the resident’s catheter bag and stated, “I don't want any part of that. I don't give a damn. Go talk to [name removed] about it.” This allegation of verbal abuse occurred on 02/25/26 sometime around 2:00 p.m. On the evening of 02/25/26 at around 8:45 p.m., the resident informed a CMA that the RN had hollered and cursed at them earlier in the day. The CMA acknowledged being told of the incident but did not immediately report it to the administrator, stating the resident wanted to self-report the next morning. The administrator reported being notified of the allegation on 02/26/26 and then had the resident complete a grievance form, after which the allegation was faxed to the state agency on 02/26/26 at 11:16 a.m. The grievance investigation substantiated verbal abuse. The administrator confirmed that staff had been educated to report suspected abuse immediately, even if unsure it was abuse, and acknowledged the incident should have been reported within 2 hours of the resident notifying the CMA.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for one resident identified as at risk for wandering and elopement. The resident, who had diagnoses including hypertension, hyperlipidemia, and severe cognitive impairment, was admitted with a history of decreased awareness and required frequent redirection. Despite multiple nursing notes documenting wandering behavior, confusion, and attempts to leave the facility, the initial elopement risk assessment did not identify the resident as at risk. The resident was observed leaving the facility on two separate occasions, once through the front door and another time walking down the highway, both times without appropriate staff intervention or supervision. Staff interviews confirmed that the resident had demonstrated confusion and exit-seeking behaviors since admission, and that interventions to prevent elopement were not implemented in a timely manner. The DON and LPN both acknowledged that the resident should have been considered an elopement risk upon admission and that supervision and preventive measures were lacking prior to the incidents. Video surveillance further revealed that the resident was able to exit the facility by following others without being stopped, indicating a failure to ensure a safe and secure environment as outlined in the facility's own policy.
Failure to Provide SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to three residents who were reviewed for beneficiary notification. Resident #56 was admitted to Part A skilled services on May 7, 2024, and discharged on July 26, 2024. Resident #53 was admitted on September 19, 2024, and discharged on September 11, 2024. Resident #13 was admitted on November 18, 2024, and discharged on December 11, 2024. During a review on December 17, 2024, the Director of Nursing (DON) reported that no SNF ABN form was provided to these residents or their representatives. Additionally, RN #1 stated that the SNF ABN form was previously included in the resident admission packet but had been removed at some point, and she was unaware of when this occurred.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was at risk for wandering and elopement. The resident, diagnosed with Alzheimer's disease and other conditions, was known to ambulate independently and had a history of attempting to leave the facility without informing staff. Despite being identified as severely cognitively impaired and at risk for elopement, the facility did not implement additional interventions after the resident previously left the facility without staff. The resident was found by the local fire department at a neighboring church, and upon return, was placed on 1:1 observation, but no further preventive measures were documented. Staff interviews revealed that the resident was known to wander the halls and approach exit doors, but there was no awareness of the resident ever leaving the premises prior to the incident. The facility's Elopement Risk Evaluation and care plan acknowledged the resident's risk, yet failed to include specific interventions to prevent future elopements. The administrator confirmed that while staff were familiar with the resident's wandering behavior, no additional interventions were added following the elopement incident.
Failure to Provide Written Grievance Decision and Address Complaint
Penalty
Summary
The facility failed to issue a written grievance decision upon request and did not address the grievance in its entirety for a resident. The grievance policy and procedure, which was not dated, stated that the facility would provide a prompt and equitable resolution of complaints and grievances, including providing a written summary of the report to the resident if requested. However, in the case of a grievance filed by a resident regarding a staff member's rudeness, the facility did not provide a written summary to the resident, despite the resident's request. The grievance form documented that the staff member was enforcing smoking regulations, but it did not address the complaint about the staff member's rudeness, nor did it include the date the grievance was discussed with the resident. Interviews with the facility's administrator and activity manager revealed that the grievance was not fully addressed, and the resident did not receive a copy of the grievance report as requested. The administrator believed the grievance was an internal document and did not provide a copy to the resident. The activity manager confirmed that the grievance about the staff member's rudeness was not addressed and that the resident's request for a copy was denied based on the administrator's instructions. A corporate consultant later confirmed that residents are allowed to have a copy of grievances they file.
Inadequate Abuse Investigation Following Resident-Staff Altercation
Penalty
Summary
The facility failed to conduct a thorough abuse investigation for a resident who was involved in an incident with a staff member. The incident occurred when the staff member attempted to read a letter with the resident, leading to a physical altercation where the resident allegedly struck the staff member. The resident claimed that the staff member had pushed them first. The facility's policy requires immediate reporting and a comprehensive investigation, including interviews with all potential witnesses and assessments of the resident's condition. However, the investigation was insufficient as the administrator did not obtain statements from the nursing staff or notify the Director of Nursing (DON) about the abuse allegation. Additionally, the incident was not reported to the local police department as required by the facility's policy. The resident involved in the incident had a medical history that included schizophrenia, COPD, essential hypertension, and recurrent depressive disorders. Despite the resident's request to report the incident to the police, the facility did not follow through with this action. The DON was informed of the incident by the resident but did not update the resident's clinical record or care plan. The administrator relied on a single witness's account and did not conduct a comprehensive investigation, as required by the facility's abuse policy. The Assistant Director of Nursing (ADON) was also unaware of the allegation until two days after the incident, indicating a lack of communication and proper procedure adherence within the facility.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident at risk for elopement, leading to multiple incidents where the resident left the facility unsupervised. The resident, who had a history of traumatic brain injury, depression, schizoaffective disorder, and dementia, was found on several occasions outside the facility without signing out or informing staff. Despite these incidents, the facility did not have a comprehensive care plan addressing the resident's elopement risk or illicit drug use. The facility's elopement policy required staff to investigate and report all cases of missing residents, but this was not consistently followed. The resident was found in various locations outside the facility, including passed out by a dumpster and in someone's yard, requiring police intervention. The facility's assessments and documentation failed to accurately reflect the resident's risk for elopement, and interventions were not officially implemented in the care plan. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's elopement risk and the need for incident reporting. The Director of Nursing and other staff members were not aware that incident reports were necessary for elopements or drug use until informed by an RN consultant. This lack of proper documentation and intervention contributed to the ongoing risk and incidents of elopement for the resident.
DON Worked as Charge Nurse with Census Over 60
Penalty
Summary
The facility failed to comply with regulations by allowing the Director of Nursing (DON) to work as a charge nurse when the resident census exceeded 60. The facility's policy explicitly states that the DON should not assume charge nurse duties when the census is above 60 residents. However, records indicate that the DON worked as a charge nurse on multiple occasions when the census ranged from 61 to 72 residents. Specifically, the DON worked as a charge nurse on June 24th, July 25th, July 31st, August 1st, 5th, and 6th, 2024, despite the facility having a census over 60 residents on these dates. Interviews with the DON and a corporate consultant confirmed these occurrences, and staffing sheets reviewed by an LPN corroborated the findings. The DON was also noted to be covering night shifts during the survey, further indicating their involvement in charge nurse duties during periods of high census.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident or their representative upon transfer to a hospital, resulting in a deficiency. The facility's Readmission to the Facility policy, dated March 1, 2022, states that a Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident meets the admission criteria. However, the clinical record for a resident with diagnoses including hypertension and diabetes mellitus did not contain documentation that the resident or representative had been provided written documentation of the bed hold policy at the time of discharge. The resident was transferred to a hospital for further evaluation of urinary retention and trouble breathing, and the discharge summary indicated that the resident was admitted to the hospital. Despite the discharge status indicating a return was anticipated, the resident was not allowed to return to the facility after being admitted to another long-term care facility following discharge from the hospital. Interviews with the Business Office Manager (BOM) and Assistant Director of Nursing (ADON) revealed a lack of awareness and communication regarding the bed hold policy, and the Administrator acknowledged that written notification should have been provided to meet regulatory requirements.
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What surveyors actually found near you
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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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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) |
|---|---|---|---|---|
| Purcell Care Center | 19.2 mi | ★★★★★ | 1 | 0 |
| Sunset Estates Of Purcell | 19.2 mi | ★★★★★ | 0 | 0 |
| Broadway Living Center | 20.1 mi | ★★★★★ | 0 | 0 |
| Lexington Nursing Home, Inc. | 20.3 mi | ★★★★★ | 2 | 0 |
| Senior Village Healthcare | 21.5 mi | ★★★★★ | 0 | 0 |
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