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 Muskogee Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, psychosis, diabetes, moderate cognitive impairment (BIMS 12), and a care plan identifying wandering risk had previously left the property multiple times. On the incident day, the resident insisted on leaving after dark, refused redirection attempts by a CNA and safety education by a nurse, became agitated, and signed out. A CNA briefly followed the resident down the street before returning to care for other residents and notifying the nurse. The resident subsequently left unsupervised, was struck by a car, and later died at the hospital. Surveyors found that the facility, which lacked an elopement policy and alert system despite known elopement risk, failed to provide adequate supervision to prevent elopement for this resident.
The facility submitted inaccurate PBJ staffing data to CMS for the fourth quarter of 2024, despite having adequate RN and licensed nurse coverage. The error was attributed to an employee who had previously submitted incorrect data at another facility and was recently let go. The facility lacked a policy for entering PBJ report data.
The facility failed to include required information on SNF ABN forms for two residents, omitting reasons for non-coverage and estimated costs. The infection preventionist, tasked with creating these forms, was unaware of these requirements. The administrator admitted there was no policy for completing the forms, despite their importance for informed resident decisions.
The facility failed to ensure licensed nurses were competent by not conducting skills checks and documenting results. An LPN's file lacked a skills review, and the DON confirmed that skills checks had not been performed since 2021 due to the previous DON discontinuing the practice. There was no policy or procedure in place for skills checks.
The facility failed to implement an enhanced barrier precaution policy to prevent the spread of multidrug-resistant organisms, as observed by the absence of signage and staff unfamiliarity with EBP. Additionally, an LPN did not perform hand hygiene during tracheostomy care for a resident, failing to change gloves between dirty and clean steps, contrary to the facility's policy.
A facility failed to consistently fill out and return dialysis communication forms for a resident with end-stage renal disease. The resident was scheduled for dialysis three times a week, but only five forms were found in their health record out of 26 sessions. Staff interviews indicated that the forms were not always returned from dialysis, and the administrator recognized the need for improvement in this process.
A facility failed to conduct routine HgbA1C lab tests for a resident with type two diabetes, as ordered by a physician. Despite a physician's order for quarterly tests, the resident's electronic health record showed no documentation of the tests being conducted since July 2024. The facility's QA committee identified this issue in October 2024, but the tests had not been completed by January 2025. The DON emphasized the necessity of completing lab work as ordered for informed care decisions.
A facility failed to collect required HgbA1C labs for a resident, as identified by the QA committee. Despite an active physician's order for quarterly lab draws, the labs had not been collected since July 2024. The QA committee identified the issue in October 2024, but the labs remained uncollected by January 2025, highlighting a lapse in the facility's quality assurance process.
Failure to Supervise Cognitively Impaired Resident Leading to Elopement and Fatal Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known cognitive impairment and wandering risk. A quarterly assessment documented that the resident had moderate cognitive impairment with a BIMS score of 12, and the face sheet listed diagnoses including dementia, diabetes, and psychosis. The resident’s care plan identified the resident as being at risk for wandering. The administrator later stated that this resident had left the facility property approximately three times prior to the incident under investigation. The administrator also stated the facility did not have an alert system and had no policy regarding wandering or elopement. On the day of the incident, nursing documentation showed that at approximately 8:00 p.m. the resident insisted on leaving the facility. A CNA attempted twice to redirect the resident due to it being dark outside, and the nurse educated the resident about the safety concerns of walking in the dark while wearing dark clothing. The resident became agitated, cursed at staff, and then signed themself out of the facility. The nurse attempted to contact the resident’s family by phone, leaving voicemails and receiving no answer. CNA #2 reported seeing the resident sign out, telling the resident it was not a good idea, and then following the resident down the street for an undetermined distance before returning to the facility to care for other residents and informing the nurse. Subsequently, a police department case report documented that the resident was struck by a car, rolled onto the hood, and struck the windshield. An EMS run report showed that CPR was initiated by EMS and a police officer, an automated chest compression device was applied, and the resident was later pronounced deceased at the hospital. Surveyors determined that the facility failed to ensure adequate supervision to prevent elopement for this resident, despite the resident’s known wandering risk and prior episodes of leaving the property. The administrator identified two residents as being at risk for elopement at the time of the survey, and the survey findings concluded that the facility failed to provide adequate supervision to prevent elopements for one of three sampled residents reviewed for accident hazards.
Removal Plan
- Perform updated wandering risk assessments for all residents.
- Relocate any new admission or resident who develops wandering behavior to a facility with wander guard and secured doors or to the resident’s chosen home setting.
- Provide one-to-one supervision for any resident exhibiting wandering behavior until the physician assesses and the family and facility determine a plan.
- If a resident elopes and does not comply with staff direction, call 911 and the family immediately and keep staff with the resident.
- Develop and update individualized care plans for all residents, including interventions for wandering risk.
- Secure facility doors so staff must assist anyone entering or exiting.
- Require family and resident to sign a sign-out form when leaving the facility.
- Educate all staff on the sign-out process and related changes.
- If a resident leaves without signing out, call 911 and the family immediately.
- Change door access codes.
- Post signage instructing visitors to call the facility if no staff are present at the front entrance.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure accurate staffing information was submitted to CMS for the PBJ reports for the fourth quarter of 2024. A review of the facility's daily staffing reports indicated that the facility had adequate RN coverage, licensed nurse coverage, and weekend staffing during this period. However, the CMS PBJ Staffing Data Report for the same quarter documented that the facility had not provided the required RN or licensed nurse coverage. The administrator acknowledged that the submitted information was inaccurate and attributed the error to an employee who had previously submitted incorrect data at another facility. This employee had been recently let go, and the facility lacked a policy or procedure for entering PBJ report data.
Incomplete SNF ABN Forms for Residents
Penalty
Summary
The facility failed to ensure that SNF ABN forms included the required information for two residents reviewed for skilled services beneficiary review. Specifically, the SNF ABN forms for these residents did not document the reasons for non-coverage and the estimated cost of those services. The infection preventionist, who was responsible for creating and presenting these forms to residents, was unaware that this information was required. Additionally, the facility administrator acknowledged the absence of a policy or procedure for completing the SNF ABN forms, despite recognizing their importance for residents to make informed decisions about their care.
Lack of Skills Checks for Licensed Nurses
Penalty
Summary
The facility failed to ensure that licensed nurses were competent to perform their duties by not conducting skills checks and documenting the results for each licensed nurse. A review of the employee file for one LPN revealed the absence of a skills review. The Director of Nursing (DON) confirmed that skills checks had not been performed for the current licensed nurses because the previous DON had discontinued the practice. The administrator and assistant administrator corroborated that no skills checks had been conducted since 2021, and there was no facility policy or procedure in place regarding skills checks.
Failure to Implement EBP and Ensure Hand Hygiene During Tracheostomy Care
Penalty
Summary
The facility failed to implement an enhanced barrier precaution (EBP) policy to prevent the spread of multidrug-resistant organisms. During a tour of the facility, it was observed that there was no signage indicating that EBP was in place to protect at-risk residents. Interviews with staff members, including two CNAs and an LPN, revealed that the facility was either not using EBP or in the process of implementing it. The infection preventionist confirmed that EBP was not currently being used in the facility. Additionally, the facility failed to ensure proper hand hygiene during tracheostomy care for a resident with a tracheostomy. An LPN was observed performing tracheostomy care without cleaning their hands before donning gloves. The LPN did not change gloves between the dirty and clean steps of the procedure, which is contrary to the facility's tracheostomy care policy. The LPN acknowledged the oversight and attributed it to nervousness. The DON expressed surprise at the LPN's performance and emphasized the importance of infection prevention and the use of personal protective equipment.
Inconsistent Dialysis Communication Forms for Resident
Penalty
Summary
The facility failed to ensure that dialysis communication forms were consistently filled out and returned for a resident with end-stage renal disease who required dialysis services. The resident had a physician's order to receive dialysis three times a week, and records showed they were transported to dialysis 26 times over two months. However, only five dialysis communication forms were found in the resident's health record. Interviews revealed that the nurse on duty was responsible for sending the form with the resident to dialysis and ensuring its return, but the forms did not always make it back to the facility. The administrator acknowledged the need for improvement in ensuring the forms were returned and filed appropriately.
Failure to Conduct Routine HgbA1C Tests for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident with type two diabetes, who was receiving routine insulin, had their HgbA1C lab tests collected as ordered by a physician. The physician's order, dated August 12, 2019, specified that the resident was to have HgbA1C labs drawn each January, April, July, and October. However, a review of the resident's electronic health record revealed no documentation of the HgbA1C being collected since July 2024. The facility's Quality Assurance (QA) committee identified this oversight in October 2024, but the lab tests had still not been conducted by January 2025. The Director of Nursing (DON) acknowledged the importance of completing lab work as ordered to enable providers to make informed care decisions.
Failure to Collect Required Lab Work for a Resident
Penalty
Summary
The facility failed to ensure that lab work identified by the QA committee as not having been done was collected for a resident. An active physician's order required the resident to have HgbA1C labs drawn quarterly, but a review of the resident's electronic health record revealed that the labs had not been collected since July 2024. In October 2024, the QA committee identified that the previous Director of Nursing had not been monitoring labs, and the resident's HgbA1C had not been collected. Despite this identification, the labs had still not been collected by January 2025, indicating a failure in the facility's quality assurance process.
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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) |
|---|---|---|---|---|
| Broadway Care & Rehab Center | 0.4 mi | ★★★★★ | 0 | 0 |
| York Manor Nursing Home | 1 mi | ★★★★★ | 24 | 0 |
| Pleasant Valley Health Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Eastgate Village Care & Rehab Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Brentwood Extended Care & Rehab | 3.3 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.