Below 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 Eastgate Village Care & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia and a documented history of wandering and exit-seeking behaviors was able to leave the facility unsupervised by following a food delivery person out the front entrance. Despite care plan interventions and a wanderguard on the resident's wheelchair, the resident used a walker without a wanderguard to exit and was missing for about an hour before being found by police in a nearby field.
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their medical documentation. A resident with cerebral palsy was incorrectly marked as comatose despite being alert and communicative. Another resident with atrial fibrillation was wrongly documented as receiving anticoagulant medications, and a resident with dementia was inaccurately assessed regarding antipsychotic medication use. These errors were confirmed through record reviews and staff interviews.
A facility failed to update a care plan for a resident with cerebral palsy and quadriplegia, inaccurately listing them as an elopement risk. Despite being bedbound and requiring total care, the care plan did not reflect the resident's true condition, as confirmed by staff and observations.
A housekeeper in the facility failed to follow proper infection control practices by transporting soiled linen without bagging it and without wearing gloves. The linen, which had a red substance later identified as ketchup, was carried from a couch in B hall to the soiled utility room. The DON and infection preventionist were informed of the breach, and it was noted that the staff member was new and needed further education.
A facility failed to notify a resident's legal representative about the treatment for a UTI. The resident, with cerebral palsy and other conditions, was not reported to their representative until the representative called to check on them. A physician's order for Macrobid was documented, but the ADON could not produce notification documentation.
The facility did not provide ABNs to two residents discharged from skilled services who remained in the facility as LTC residents. Both residents had skilled days remaining, but neither they nor their representatives received the required notices. The business office manager, responsible for issuing these notices, confirmed the oversight.
The facility failed to provide bed hold notices to two residents transferred to the hospital, as required by guidelines. One resident with dementia and another with cerebral palsy and ostomy status were affected. Staff interviews revealed confusion about responsibility for issuing notices, and the DON admitted the oversight.
A facility failed to implement a behavioral flow sheet for a resident with dementia, anxiety, and mood disorder, who was on antipsychotic medication. The care plan required behavior monitoring, but the electronic clinical record lacked the necessary documentation. An LPN was unaware of the requirement, and the DON admitted the oversight.
A facility failed to follow its policy requiring weekly weight monitoring for four weeks after a resident's admission. A resident with dementia was admitted, but their weights were only recorded monthly, contrary to the facility's guidelines. The DON acknowledged the oversight, noting the absence of a physician's order for weight frequency, which led to the deviation from the policy.
The facility failed to secure medications on two of six observed carts. An unlocked cart was found unattended on E hall, and another was unlocked by the nurses' station. Staff admitted to forgetting to lock the carts, contrary to protocol requiring carts to be locked when not in use.
The facility failed to date and label food items in the kitchen, as required by their Food Storage policy. Inspections revealed undated ice cream, milk, and puree diet snacks, as well as unlabeled foam cups in the refrigerator. A dietary aide confirmed the preparation of the snacks and identified the contents of the foam cups. The dietary manager stated that staff were supposed to label and date foods before refrigeration.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure a safe environment for a resident with a known history of wandering and elopement risk. The resident, who had diagnoses including dementia, hypertension, and heart failure, had previously demonstrated exit-seeking behaviors, including verbal aggression, threats to leave, and attempts to exit through windows and doors. Despite being identified as at risk for elopement and having multiple care plan interventions in place, the resident was able to leave the facility by following a food delivery person out the front entrance. The resident was missing for approximately one hour before being located by police in a nearby field and returned to the facility. Documentation showed that the resident had a history of wandering, including incidents where the resident attempted to leave through windows and was found at exit doors. The resident's care plan included interventions such as disguising exits, using a wanderguard, frequent observation, and diversional activities. However, on the day of the incident, the resident was able to elope using a walker that did not have a wanderguard, as opposed to their wheelchair which was equipped with one. The facility's failure to ensure all necessary elopement prevention measures were in place and to provide adequate supervision directly led to the resident's unsupervised exit from the property.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #1, diagnosed with cerebral palsy, ostomy status, and UTI, was inaccurately marked as comatose on their admission assessment, despite multiple progress notes indicating they were alert and capable of non-verbal communication. Observations and staff interviews confirmed the resident's ability to respond to stimuli and communicate using eye movements, contradicting the comatose coding on the MDS. Resident #52, with a diagnosis of paroxysmal atrial fibrillation, was incorrectly documented as having received anticoagulant and antiplatelet medications during the assessment's look-back period, although the electronic clinical record showed no such administration. Similarly, Resident #60, diagnosed with dementia, had an active order for Quetiapine, an antipsychotic medication, but their annual assessment failed to reflect this medication use since the last admission or prior assessment. These inaccuracies were confirmed through record reviews and staff interviews, highlighting the facility's failure to adhere to the MDS 3.0 policy and RAI User's Manual guidelines for accurate resident assessments.
Failure to Update Care Plan for Bedbound Resident
Penalty
Summary
The facility failed to ensure that a care plan was updated or revised for one of the sampled residents. The resident in question had diagnoses including cerebral palsy, ostomy status, and a urinary tract infection. Despite these conditions, the care plan, last revised on January 9, 2025, inaccurately included a potential for elopement risk or wander risk. However, an Elopement Evaluation conducted on December 23, 2024, showed an elopement score of 0.0, indicating no history of elopement or wandering aimlessly. Observations and interviews with facility staff revealed that the resident was bedbound, required total care, and used a mechanical lift, making them not an elopement risk. The Director of Nursing confirmed that the care plan did not accurately reflect the resident's condition, as the resident had cerebral palsy, quadriplegia with muscle contractures, and was not capable of elopement. This discrepancy between the resident's actual condition and the care plan represents a failure in maintaining an accurate and updated care plan as per the facility's policy.
Infection Control Breach in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices during the transportation of soiled linen. During an observation, a housekeeper was seen carrying white linen with a red substance on it to the soiled utility room without placing it in a bag and without wearing gloves. The housekeeper admitted to not following the correct procedure, which involves bagging soiled linen at the point of collection and using a leak-proof container for transport. The linen was found on a pillow on a couch in B hall, and the housekeeper initially claimed it was not soiled, later identifying the substance as ketchup. The Director of Nursing (DON) was made aware of the incident and acknowledged that the staff member involved was new and required education. The infection preventionist was also informed of the infection control concern and indicated that they would address it promptly. The facility's handling linen/laundry policy, dated July 2024, outlines the necessary precautions for handling soiled linen, which were not followed in this instance.
Failure to Notify Legal Representative of UTI Treatment
Penalty
Summary
The facility failed to notify a resident's legal representative about the treatment for a urinary tract infection (UTI) for one resident reviewed for notification of change. The resident, who had diagnoses including cerebral palsy, ostomy status, and hyponatremia, was not reported to their legal representative about the UTI until the representative called to check on the resident. A physician's order was documented for Macrobid, an antibiotic, to be administered via peg-tube for the UTI. The Assistant Director of Nursing (ADON) stated that the process for a change in condition involved notifying the medical director, family, Director of Nursing (DON), and hospice if appropriate, and completing a form in the electronic medical record. However, the ADON was unable to produce documentation of notification for the date in question.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide advance beneficiary notices (ABNs) to two residents who were discharged from skilled services but remained in the facility as long-term care residents. Resident #10 was discharged from skilled services on December 26, 2024, and Resident #18 on September 18, 2024. Both residents had skilled days remaining, yet neither they nor their representatives received the required ABNs. The business office manager, responsible for providing these notices, confirmed that ABNs were typically given to residents with Medicare, while Notices of Medicare Non-Coverage (NOMNC) were provided to those with Health Maintenance Organization plans. The administrator also confirmed that the business office manager was tasked with issuing beneficiary notices upon discharge from skilled services.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a notice of bed hold to two residents who were transferred to the hospital, as required by state and federal guidelines. Resident #80, diagnosed with dementia, was discharged to the hospital on two occasions, but the electronic clinical record did not show that a bed hold notice was provided to the resident or their representative. Interviews with facility staff, including the infection preventionist/charge nurse, BOM, LPN, and DON, revealed confusion and lack of clarity regarding the responsibility for providing the bed hold notice. The DON admitted that the facility had not been providing these notices and was unaware of where such documentation was kept. Similarly, Resident #1, who had diagnoses including cerebral palsy and ostomy status, was sent to the hospital, but there was no documentation of a bed hold policy being provided. When questioned, the ADON was unsure about the documentation process, and the DON indicated that the notices were supposed to be kept in a folder at the nurses' station. However, the DON admitted that they did not have the required documentation for Resident #1 and acknowledged the oversight in the presence of the administrator.
Failure to Implement Behavioral Monitoring for Resident on Antipsychotics
Penalty
Summary
The facility failed to implement a care plan intervention for a behavioral flow sheet for a resident diagnosed with dementia, anxiety, and mood disorder. The care plan, dated December 20, 2024, required behavior monitoring for residents taking antipsychotic medications, specifically through a behavior monitoring flow sheet. However, a review of the electronic clinical record revealed that no such flow sheet had been implemented for the resident. During interviews, an LPN was unaware of the requirement for a behavioral flow sheet for the resident, and the DON acknowledged that the behavioral monitoring had not been documented on the treatment record as intended.
Failure to Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to adhere to its Weight and Hydration Management Practice Guidelines policy, which required residents to be weighed weekly for four weeks upon admission. This deficiency was identified for a resident diagnosed with dementia, who was admitted on 10/28/24. The resident's clinical record showed weights were only recorded on 11/04/24, 12/01/24, and 01/01/25, indicating that weekly weights were not obtained as required. The Director of Nursing (DON) acknowledged the oversight, noting that there was no physician's order specifying the frequency of weight monitoring, leading to the resident being weighed monthly instead of weekly as per the facility's policy.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure the security of medications on two of the six medication/treatment carts observed. On February 4, 2025, at 3:40 p.m., an unlocked and unattended medication cart was observed on E hall across from room E1, containing resident medications with no staff nearby. CMA #1 later returned to lock the cart, admitting they forgot to lock it after retrieving a laptop. On February 6, 2025, at 3:36 p.m., the B/C hall treatment cart was found unlocked by the nurses' station, with two nurses having their backs to it and CMA #2 facing it. CMA #2 subsequently locked the cart, and LPN #1 acknowledged the protocol to lock carts when not in use, attributing the oversight to loaning out a glucometer. The DON confirmed that the protocol required carts to be locked when unattended.
Failure to Date and Label Food in Kitchen
Penalty
Summary
The facility failed to ensure that foods were properly dated when opened, as observed during two separate inspections of the kitchen. The Food Storage policy, dated 10/01/18, requires that all opened and bulk items be stored in tightly covered containers, labeled, and dated to ensure freshness. During an inspection on 02/03/25, an uncovered and undated bowl of ice cream was found in the stand-up freezer, along with six cups of undated milk in the refrigerator. A subsequent inspection on 02/06/25 revealed six small, clear containers with a pink/yellow substance, identified as snacks for residents on a puree diet, which were undated. Additionally, two foam cups in the refrigerator were undated and unlabeled, with one containing milk and the other suspected to contain coffee. Dietary aide #1 confirmed the preparation of the snacks earlier that morning and identified the contents of the foam cups. The dietary manager acknowledged that staff were required to label and date foods before refrigeration.
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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) |
|---|---|---|---|---|
| York Manor Nursing Home | 1.2 mi | ★★★★★ | 24 | 0 |
| Broadway Care & Rehab Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Muskogee Nursing Center | 1.6 mi | ★★★★★ | 1 | 1 |
| Pleasant Valley Health Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Brentwood Extended Care & Rehab | 4.9 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 July 2026) and official state health department websites.