Lindsay, OK

Lindsay Nursing & Rehab

4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1103 West Cherokee, Lindsay, OK

(405) 756-4334

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

106

Certified beds

Average residents

75

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Bradford Montgomery

Operator or chain grouping

Approved since

1995-02-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

11 facilities

Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.15

Registered nurse staffing · state 0.34 · national 0.68

LPN hours / resident day

0.73

Licensed practical nurse staffing · state 0.92 · national 0.87

Aide hours / resident day

2.47

Nurse aide staffing · state 2.57 · national 2.35

Total nurse hours

3.35

All reported nurse hours · state 3.84 · national 3.89

Licensed hours

0.88

RN + LPN hours · state 1.27 · national 1.54

Weekend hours

3.23

Weekend nurse staffing · state 3.49 · national 3.43

Weekend RN hours

0.13

Weekend registered nurse coverage · state 0.29 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.03 · national 0.07

Adjusted RN hours

0.21

CMS adjusted RN staffing hours

Adjusted total hours

4.70

CMS adjusted total nurse staffing hours

Case-mix index

0.97

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

5,661

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.38

Composite VBP score used to determine payment impact.

Payment multiplier

0.9891

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.06

Performance 19.09% · Measure score 5.06 · Achievement 5.06 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

2.04

Performance 7.22% · Measure score 2.04 · Achievement 2.04 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

3.51

Baseline 4.92 hours · Performance 4.08 hours · Measure score 3.51 · Achievement 3.51 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.55%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 6.82%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.69	1.02 0.3 pts better
Drug regimen review with follow-up	95.35%	95.27% 0.1 pts better	Numerator 41 · Denominator 43
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 43
Discharge self-care score	75%	53.69% 21.3 pts better	Numerator 24 · Denominator 32
Discharge mobility score	46.88%	50.94% 4.1 pts worse	Numerator 15 · Denominator 32
Pressure ulcers or injuries, new or worsened	2.33%	2.29% About the same	Numerator 1 · Denominator 43 · Adjusted rate 2.36%
Healthcare-associated infections requiring hospitalization	7.22%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 4.13%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 78
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	81.25%	56.45% 24.8 pts better	Numerator 26 · Denominator 32
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	2.3 0.6 pts better	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.4	2.9 0.5 pts better	1.8 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.8%	90.3% 2.5 pts better	93.4% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 73.4% · Q2 98.4% · Q3 100.0% · Q4 98.6% · 4Q avg 92.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.9%	94.6% 0.7 pts worse	95.5% 1.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9%
Percentage of long-stay residents experiencing one or more falls with major injury	3.0%	4.5% 1.5 pts better	3.3% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.2% · Q3 1.4% · Q4 1.4% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.2%	3.3% 2.1 pts better	11.4% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.9% · 4Q avg 1.2%
Percentage of long-stay residents who lose too much weight	0.9%	3.6% 2.7 pts better	5.4% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.7% · Q4 0.0% · 4Q avg 0.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.1%	25.3% 2.8 pts worse	19.6% 8.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 24.1% · Q3 27.9% · Q4 28.3% · 4Q avg 28.1%
Percentage of long-stay residents who received an antipsychotic medication	32.3%	18.6% 13.7 pts worse	16.7% 15.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 37.5% · Q3 33.3% · Q4 33.3% · 4Q avg 32.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	11.1%	15.5% 4.4 pts better	16.3% 5.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 8.6% · Q3 6.2% · Q4 14.8% · 4Q avg 11.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.0%	14.1% 4.1 pts better	14.9% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 9.3% · Q3 4.9% · Q4 15.0% · 4Q avg 10.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	2.1% 2.1 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.8% 2.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.0%	17.8% 2.8 pts better	19.8% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 3.4% · Q3 13.2% · Q4 32.1% · 4Q avg 15.0%
Percentage of long-stay residents with pressure ulcers	3.9%	5.1% 1.2 pts better	5.1% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.0% · Q3 4.8% · Q4 3.8% · 4Q avg 3.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	82.1%	75.0% 7.1 pts better	81.7% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q3 80.8% · Q4 74.1% · 4Q avg 82.1%
Percentage of short-stay residents who had an outpatient emergency department visit	10.4%	17.1% 6.7 pts better	12.0% 1.6 pts better	Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 11.1% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.8%	1.9% 1.9 pts worse	1.6% 2.2 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.5%	27.0% 5.5 pts better	23.9% 2.4 pts better	Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 18.5% · Expected 20.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-18 · Fire 2024-12-18

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-09-19 · Fire 2023-09-19

10 health deficiencies

Top issue: Resident Rights (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2022-09-15 · Fire 2022-09-15

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-31

E · Potential for more than minimal harm 2024-12-18

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2025-01-31

D · Potential for more than minimal harm 2024-12-18

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-01-31

F · Potential for more than minimal harm 2023-09-19

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-03-15

F · Potential for more than minimal harm 2023-09-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-03-15

F · Potential for more than minimal harm 2023-09-19

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2024-03-15

F · Potential for more than minimal harm 2023-09-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-15

F · Potential for more than minimal harm 2023-09-19

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-03-15

F · Potential for more than minimal harm 2023-09-19

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-03-15

E · Potential for more than minimal harm 2023-09-19

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-03-15

E · Potential for more than minimal harm 2023-09-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-03-15

E · Potential for more than minimal harm 2023-09-19

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-03-15

F · Potential for more than minimal harm 2022-09-15

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2022-10-07

F · Potential for more than minimal harm 2022-09-15

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-10-07

F · Potential for more than minimal harm 2022-09-15

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2022-10-07

F · Potential for more than minimal harm 2022-09-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-07

F · Potential for more than minimal harm 2022-09-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-15

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-15

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-15

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-10-07

C · Minimal harm 2022-09-15

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-10-07

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-03

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-07-21

E · Potential for more than minimal harm 2024-12-18

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-01-23

D · Potential for more than minimal harm 2024-10-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-08-07

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-09-13

E · Potential for more than minimal harm 2024-08-07

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-09-13

E · Potential for more than minimal harm 2024-08-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-09-13

E · Potential for more than minimal harm 2024-08-07

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-09-13

D · Potential for more than minimal harm 2024-08-07

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-09-13

E · Potential for more than minimal harm 2023-09-19

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-11-01

E · Potential for more than minimal harm 2023-09-19

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-11-01

E · Potential for more than minimal harm 2023-09-19

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2023-11-01

D · Potential for more than minimal harm 2023-09-19

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2023-11-01

F · Potential for more than minimal harm 2022-09-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-10-07

Penalties and ownership