Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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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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 | — | 15 | 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 |
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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 August 2026) and official state health department websites.