Lindsay Gardens Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lindsay Gardens Nursing & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF580Jun 15, 2021

  Based on interview and record review, the facility failed to notify the physician of a change in condition for two of three sampled residents (Resident 1 and Resident 2) when the residents experienced episodes of [CONDITION(S)] (increased blood sugar). These failures resulted in Resident 1 being hospitalized and Resident 2 having the potential for adverse side effects. Findings: 1. During a review of Resident 1's Progress Notes (PN), dated 3/29/21, at 4:30 PM, the PN indicated, Resident is noted to have increase heart rate of 129 (normal range 60-100), B/P (blood pressure) 122/85 (normal range is less than 120/80), SPO2 (oxygen saturation in the blood) @ 96% (normal range 95-100 %) in room air, temp (temperature) 97.4 (normal range 97-99). Her face is flushed. […]

• No harm, potential for more than minimal, patternF656Jan 8, 2026

  Based on observation, interview, and record review the facility failed to develop and implement and revise a comprehensive care plan (CP) for three of 33 sampled residents (Resident 61, Resident 81 and Resident 36). This failure had the potential to result in Resident 61, Resident 81, and Resident 36 having an unrecognized change in condition and adverse health outcomes. Findings: During a concurrent observation and interview on 1/6/26 at 12:10 p.m. with Dietary Manager Assistant (DMA) in the kitchen, Resident 61's lunch meal plate contained a taco with a flour tortilla and ground pork, lettuce and tomatoes, a number (#) 12 scoop (1/3 cup) of beans and one slice of wheat bread. […]

• No harm, potential for more than minimal, patternF658Jan 8, 2026

  Based on observation, interview and record review, the facility failed to: 1. Obtain a physician's order for two of six sampled residents (Resident 36 and Resident 84) prior to oxygen use. This failure had the potential for Resident 84 and Resident 36 to have serious health outcomes, including hypoxia (lack of oxygen) or oxygen toxicity (too much oxygen) causing lung damage and confusion. 2. Follow physician's orders for one of six sampled resident (Resident 84) when oxygen saturation levels were not monitored. This failure had the potential to result in missed early signs of low blood oxygen levels which could lead to potential organ damage, especially to the heart and brain. Findings: 1. During an observation on 1/5/26 at 12:22 p.m. […]

• No harm, potential for more than minimal, patternF727Jan 8, 2026

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled to work in the facility for at least eight consecutive hours a day, seven day per week. This failure had the potential to adversely affect resident care. Findings: During an interview on 1/7/26 at 8:58 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated, there was an RN that worked on weekends, but was not sure if there was an RN scheduled to work on weekdays. During an interview on 1/7/26 at 9:03 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated there was an RN that worked weekends and the RN working on weekdays was the Director of Nursing (DON). During an interview on 1/7/26 at 9:10 a.m. with LVN 7, LVN 7 stated the facility had an RN who worked daily. […]

• No harm, potential for more than minimal, patternF812Jan 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure:1. The facility's 3-compartment procedure for manual dishwashing was followed by one of one sampled dietary aide (DA) 1 who washed one piece of foodservice equipment via the 3-compartment sink.2. One of five observed dietary employees (DA 2) washed their hands after a cross-contamination incident during the lunch tray line meal service for residents.These failures had the potential to place residents at risk of foodborne illness who received meals from the kitchen.Findings:1. During a concurrent observation and interview on 1/6/26 at 11:25 a.m. with DA 1 in the kitchen, DA 1 was observed washing a large mixing food container in the first sink of the 3-compartment sink. […]