Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Broadway Care & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses did not have physician-ordered antiplatelet medications held prior to scheduled pacemaker placement procedures. As a result, the resident was unable to undergo the procedures as planned due to the medications not being withheld as ordered.
A resident with severe cognitive impairment eloped from a locked unit by exiting through a window, which was not adequately secured to prevent tampering from inside. The resident was later returned by law enforcement, and facility records did not specify how far the resident traveled or the exact duration of absence.
Two residents with severe cognitive impairment experienced harm due to unsafe practices: one sustained burns after being served excessively hot coffee, and another ingested Pine-Sol left in a Styrofoam cup on a housekeeping cart, leading to hospitalization for respiratory failure. Staff interviews revealed inconsistent knowledge and application of safety protocols regarding hot liquids and chemical storage.
A resident on Enhanced Barrier Precautions for a tracheostomy and catheter was observed receiving tube feeding care from an LPN who failed to wear a gown as required by facility policy, despite PPE being available in the room. The LPN acknowledged not following the EBP protocol, and the DON confirmed the policy and staff training requirements.
A resident with cognitive impairment and high dependency for care was admitted with intact skin and placed on a prophylactic skin care regimen, including zinc oxide and a repositioning program. However, there was no documented ongoing assessment or intervention for skin integrity, and the resident was later hospitalized with deep tissue injuries to the sacrum and heel. The wound care nurse confirmed the presence of redness and the use of zinc, but could not provide documentation of wound progression or interventions.
A resident with severe cognitive impairment was involved in an incident where another resident grabbed them by the neck and was verbally aggressive until staff intervened. The facility did not conduct or document a thorough investigation, as required by policy, and failed to collect or include staff or resident interviews related to the incident.
A wound care nurse provided care to a resident with a pressure ulcer and multi-drug resistance without donning a gown or mask, despite facility policy and signage requiring enhanced barrier precautions. The nurse acknowledged the need for these precautions but did not follow them during the observed wound care.
A resident with severe cognitive impairment was physically restrained by a visitor in their room, despite the resident's attempts to leave and requests for the visitor to be quiet. The incident occurred in the early morning, and staff intervention was required to ensure the resident's safety. The visitor refused to leave the facility, necessitating police involvement to escort them out. The facility's abuse prevention policy was not effectively implemented, leading to this deficiency.
A facility failed to honor a resident's right to receive visitors of their choosing, as they restricted visitation based on the wishes of the resident's POA. Despite the facility's policy allowing 24-hour access to visitors with the resident's consent, the facility informed a friend of the resident that they could not visit, following the POA's instructions. Staff interviews confirmed that the facility should not have restricted visitation based on the POA's wishes.
Failure to Follow Physician Orders for Medication Holds Prior to Procedure
Penalty
Summary
The facility failed to follow physician orders for a resident who was scheduled for two pacemaker placement procedures. Physician orders directed that specific antiplatelet medications, including aspirin EC and Plavix, be held prior to the procedures. However, a review of the resident's records showed that these medications were not discontinued or held as ordered. As a result, the resident was unable to undergo the scheduled pacemaker placement procedures on the intended dates. The resident involved had diagnoses including metabolic encephalopathy and cerebral ischemia, with a BIMS score indicating severe cognitive impairment. The Director of Nursing (DON) confirmed that the medication was not withheld for the appropriate length of time, which led to the missed procedures. The issue was identified after the second missed procedure, and it was noted that the DON had not been informed of the first missed procedure.
Elopement Due to Inadequate Supervision and Window Security
Penalty
Summary
A resident with a diagnosis of unspecified dementia and a BIMS score of 3, indicating severe cognitive impairment, eloped from a locked unit within the facility. The incident report indicated that the resident left the facility through a window and was returned by local law enforcement. The facility's investigation did not document how far the resident traveled after leaving or the exact time frame during which the resident was missing. At the time of the incident, the resident was not accounted for during a routine check, and the facility initiated a search and notified police. Record review showed that the facility did not have adequate measures in place to prevent the resident from leaving through a window, as the window mechanisms allowed for partial opening and could be tampered with from inside. Maintenance logs and resident records were reviewed, but there was no indication that daily checks on windows in the locked unit or weekly checks in the rest of the building were sufficient to prevent such an incident. The resident, when interviewed, could not recall how they exited the building or how far they traveled before being found.
Failure to Prevent Accident Hazards: Hot Liquid Burns and Chemical Ingestion
Penalty
Summary
A deficiency was identified when a resident with severely impaired cognition and a history of dementia, delusional disorders, and lack of coordination sustained burn injuries to both thighs after spilling hot coffee on themselves. The resident required supervision for eating and was observed to have shaky hands while feeding. Coffee was served at temperatures exceeding 150 degrees Fahrenheit, with staff and surveyors noting that the beverage was very hot and could cause burns. There was no consistent documentation that all staff had been in-serviced on safe coffee temperatures, and staff interviews revealed uncertainty about proper procedures for checking beverage temperatures before serving. Another deficiency occurred when a resident with severe cognitive impairment, intellectual disability, and a history of aspiration pneumonitis ingested Pine-Sol that had been left in a Styrofoam cup on a housekeeping cart. The resident required supervision for eating and was able to access the chemical, mistaking it for coffee. Following ingestion, the resident experienced vomiting, respiratory distress, and was subsequently hospitalized with acute respiratory failure and aspiration pneumonitis. Staff interviews indicated that chemicals were supposed to be locked and labeled, but the incident demonstrated a failure to secure hazardous substances. Both incidents involved residents with significant cognitive impairments who required supervision and were exposed to preventable hazards due to lapses in staff adherence to safety protocols. The facility failed to ensure that hot beverages were served at safe temperatures and that chemicals were properly secured, resulting in harm to the residents involved.
Failure to Ensure Proper PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). During observation, signage indicating EBP was present on the resident's door, and the resident was receiving tube feeding. An LPN entered the resident's room, wearing gloves but did not don a gown as required by the facility's EBP policy, while accessing the resident's feeding tube. The LPN exited and re-entered the room, again applying only gloves and not a gown, despite PPE supplies being available inside the room. The facility's policy, dated 05/15/24, specifies that both gown and gloves are required for high-contact care activities, including enteral tube care, under EBP. The LPN acknowledged awareness of the policy and admitted to not following the required PPE protocol. The DON confirmed the EBP requirements and stated that staff had been provided with badges containing EBP information and had received in-service training. The deficiency was identified for one of three sampled residents observed for EBP, in a facility with 75 residents.
Failure to Monitor and Intervene for Pressure Ulcer Prevention
Penalty
Summary
A resident with dementia and cognitive communication deficit was admitted to the facility with intact skin and no evidence of pressure ulcers. The resident was dependent on one to two persons for transfers and toilet hygiene. Physician orders were in place to apply zinc oxide ointment to the buttocks and sacrum every shift for skin integrity prophylaxis, and a turn and reposition program was documented. Despite these measures, there was no documentation of ongoing assessment or intervention for skin integrity after the initial admission and subsequent observations. The resident was later transferred to the emergency room due to a change in condition, where a hospital wound assessment identified deep tissue injuries (DTIs) to the sacrum and left heel. The facility's wound care nurse confirmed that redness was noted and zinc was applied, but could not provide documentation of the wound's progression or interventions prior to hospital transfer.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving a resident with severe cognitive impairment and intellectual disabilities. According to the records, an incident occurred in which one resident grabbed another by the neck and was verbally aggressive until a staff member intervened and separated the two. The facility's Abuse Prevention policy requires that all investigations be thorough and that results be reported to the administrator and appropriate officials within five working days. Despite this policy, documentation revealed that the investigation was incomplete. The only evidence provided was a single, unlabeled document summarizing the incident, with no supporting staff or resident interviews included in the records. The administrator confirmed that no additional statements or interviews were conducted or documented beyond what was submitted in the final report.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain infection control and follow evidence-based practices (EBP) during wound care for a resident requiring enhanced barrier precautions. Observation showed that the wound care nurse entered the resident's room, washed hands, donned gloves, and provided wound care without wearing a gown or mask, despite signage and policy indicating the need for these precautions. The resident had a pressure ulcer of the sacral region and was resistant to multiple antimicrobial drugs, with a care plan specifying enhanced barrier precautions to reduce multi-drug resistant organisms. The wound care nurse acknowledged awareness of the need for additional precautions but did not don a gown or mask prior to providing care.
Failure to Protect Resident from Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a visitor who physically restrained a resident. The resident, who had severe cognitive impairment and diagnoses including anxiety and repeated falls, was found by a nurse being held by the wrists by a visitor in the doorway of their room. The incident occurred in the early morning hours when the visitor was being loud, and the resident attempted to leave the room to seek help. Despite the resident's request for the visitor to be quiet and to leave, the visitor refused and physically restrained the resident, preventing them from leaving the room. The nurse intervened by instructing the visitor to release the resident and escorted the resident to the nurse's desk for safety. The visitor refused to leave the facility when asked by the staff, prompting the staff to call the police, who then escorted the visitor out. Interviews with the resident, a CNA, and an LPN confirmed the sequence of events, highlighting the facility's failure to prevent the abuse and ensure the resident's safety. The facility's abuse prevention policy was not effectively implemented in this instance, as the visitor was able to enter the facility and interact with the resident in a harmful manner.
Facility Failed to Honor Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, as evidenced by the restriction of visitation based on the wishes of the resident's Power of Attorney (POA). The facility's visitation policy, revised in February 2017, allows residents to receive visitors at any time, subject to the resident's wishes. However, in two documented instances, the facility contacted the resident's POA, who did not want a friend of the resident to visit. The facility then informed the friend that they could not visit, and in one instance, the POA instructed the facility to call the police if the friend attempted to visit. The resident involved had diagnoses including hypertension and anxiety disorder. Interviews with facility staff, including an LPN and the Social Services Director (SSD), revealed that the facility should not have restricted visitation based on the POA's wishes. The Director of Nursing (DON) and the Corporate Administrator acknowledged that the facility could not restrict visitation based on the POA's wishes, as informed by the ombudsman during a care plan meeting. This deficiency highlights a failure to adhere to the facility's visitation policy and respect the resident's rights.
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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 Muskogee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Muskogee Nursing Center | 0.4 mi | ★★★★★ | 1 | 1 |
| York Manor Nursing Home | 0.7 mi | ★★★★★ | 24 | 0 |
| Pleasant Valley Health Care Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Eastgate Village Care & Rehab Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Brentwood Extended Care & Rehab | 3.6 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 July 2026) and official state health department websites.