Average — CMS composite of the measures below.
The next survey window likely opens around October 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 The Springs Skilled Nursing And Therapy during CMS and state inspections, most recent first.
During a meal service, food temperatures were not maintained in accordance with professional standards, as a chicken patty was served at 95.6°F in the dining area after being recorded at a much higher temperature in the kitchen. Staff acknowledged that food should be reheated if not at the desired temperature and attributed the temperature drop to food not being covered during serving. The facility lacked a formal policy on maintaining warm foods, and 86 residents were served meals during this time.
An unlocked and unattended treatment cart on the 400 hall was observed containing multiple medicated creams and wound products, and a multi-dose vial of tuberculin protein derivative in the 300/400 med room was found without an open date. RN and the DON stated the vial required an open date and that med and treatment carts were to be locked and not left unattended.
A resident with dementia passed away after being discharged to the ER, and their trust account balance of $1,282.09 was not conveyed to the family within the required 30-day period. The BOM attempted to resolve an SSA overpayment but lacked documentation of communications, resulting in a delay in closing the account as per policy.
Surveyors found a shower room door ajar and unattended on the 400 hall, with a spray bottle of QUAT STAT 5 disinfectant left unsecured inside. The chemical, which requires locked storage due to its hazardous nature, was accessible because the door was not fully closed, despite having an automatic lock and passcode entry. Facility leadership confirmed that chemicals are to be kept locked away from residents.
A resident identified as at risk for weight fluctuations did not have monthly weights obtained or documented for two consecutive months, despite physician orders and care plan requirements. Staff interviews revealed that both nursing and CNA staff were responsible for obtaining weights, and the MDS coordinator was responsible for ensuring compliance, but no documentation of weights or refusals was found in the clinical record.
A resident with CHF and intact cognition was discharged home with family and home health services, but the facility failed to complete a discharge summary with a recapitulation of the resident's stay. The DON stated MDS coordinators usually completed discharge summaries and confirmed the summary had not been completed for the resident's planned discharge.
A resident with depression and a psychotic disorder had a level 2 PASARR recommending monthly psychiatric follow-up and weekly counseling/psychotherapy, but the facility did not have the PASARR in the chart or electronic record and did not incorporate the recommendations into the care plan. Staff stated the PASARR had not been received until later, and the care plan only noted psychiatric services would evaluate and treat as indicated.
Failure to provide a written baseline care plan summary to a resident or resident representative. The record showed the resident was admitted with a baseline care plan and that admission orders were given, but there was no documentation that a summary of the baseline assessment/care plan or copies of the MAR or treatment record were provided. The MDS coordinator and DON both reviewed the chart and confirmed the missing documentation.
Care Plan Did Not Reflect Bed Rail Use: A resident had a bed rail observed on the right side of the bed, but the updated care plan did not include bed rail use. The resident’s assessment showed a BIMS score of 13 and a dx of depression. The QM nurse, MDS coordinator, and DON all confirmed the bed rail had not been addressed in the care plan, even though the DON stated the resident had used it for about 1.5 years.
Failure to document post-dialysis assessments for a resident receiving dialysis. A resident with a dialysis port and AV fistula had orders for dialysis-related monitoring, but the next month’s treatment sheet did not include the dialysis orders or required assessments. Staff completed the pre-dialysis form and sent it with the resident, but the MDS coordinator and DON stated the facility did not document a post-dialysis assessment in the chart because the orders were not resumed after the resident returned from the hospital and the form used did not have space for the facility’s post assessment.
Missing assessment and consent for bed rail use: A resident had a bed rail observed in the up position, but the record did not show an assessment for bed rail use or informed consent. The resident had a BIMS score of 13 and a dx of depression. The care plan did not reflect bed rail use, and the QMN and DON confirmed the assessment, consent, and physician order were not completed or documented.
Failure to regularly inspect bed rails as part of the maintenance program for a resident using a bed rail. A bed rail was observed on the resident’s bed, and the resident had a BIMS score of 13 with a dx of depression. The maintenance supervisor stated bed rails were installed as indicated by the DON but were not regularly inspected, and the administrator stated the facility had no policy for bed rails, bed safety, or bed inspection. The DON stated the resident had used a bed rail for about 1.5 years.
The facility failed to ensure resident assessments were completed within the required timeframe for 10 out of 11 residents reviewed. The MDS Coordinator reported being pulled to the floor to cover staffing, which prevented timely completion of assessments.
The facility failed to ensure that oxygen and humidifier tubing was changed monthly for three residents with COPD. Observations revealed that the tubing and humidifiers were not changed as per the facility's policy, and the DON acknowledged issues with monitoring these changes.
The facility failed to provide adequate staffing, resulting in two residents missing several scheduled baths. One resident with end-stage renal disease and congestive heart failure missed four scheduled baths in May 2024, while another resident with COPD and a history of falling missed three. Both residents reported that staff cited insufficient staffing as the reason for not providing the baths.
The facility failed to administer Levothyroxine as ordered for a resident with hypothyroidism. The MAR for April and May 2024 showed multiple blanks for the 6:00 a.m. dose, indicating the medication was not given. A CMA confirmed that the night shift nurse was responsible for these doses.
Failure to Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to serve food in accordance with professional food service safety standards during a meal service observed by surveyors. The cook recorded a chicken patty temperature of 192°F and a ground chicken patty at 141°F in the kitchen, but later, a dietary aide measured the chicken patty at only 95.6°F in the dining area. The dietary aide explained that food was tempted before leaving the kitchen, transferred in a hot box, and then placed on a steam table in the dining area, with temperatures to be recorded again. The aide acknowledged that if food was not at the desired temperature, it should be returned to the kitchen for reheating, and suggested that uncovered food during serving may have caused the temperature drop. The dietary manager confirmed the lack of a facility policy on maintaining warm foods and attributed the temperature drop to food not being covered while serving, stating that their personal practice was to check food temperatures before, during, and after serving. A total of 86 residents were identified as eating meals prepared in the kitchen during this observed meal service.
Unsecured treatment cart and unlabeled tuberculin vial
Penalty
Summary
The facility failed to securely store medicated creams on 1 of 1 treatment carts located on the 400 hall. On 09/17/25 at 11:58 a.m., the 400 hall treatment cart was observed unlocked and unattended. The cart contained lidocaine 2.5%/Prilocaine 2.5% medicated cream, cadexomer lodine gel, Vashe wound solution, Santyl cream, mupirocin ointment, and coloplast cream. The DON identified three medication rooms and three treatment carts in the facility, and stated medication carts and treatment carts were to be locked before stepping away from the cart and were not to be left unattended and unsecured. The facility also failed to label the open date on a multi-dose vial of tuberculin protein derivative stored in the 300/400 medication room. On 09/23/2025 at 3:38 p.m., an open multi-dose vial of tuberculin protein derivative was observed in the refrigerator bin with no open date and no box present for the vial. RN #1 stated the vial did not have a documented open date and that the vial read to discard it 30 days after it was opened. The DON stated that if the vial was opened, it had to have a date it was opened and that tuberculin protein derivative was to be discarded 30 days after opening.
Failure to Timely Convey Resident Funds After Death
Penalty
Summary
The facility failed to ensure the timely conveyance of personal funds for a resident who had died, as required by policy and state guidelines. Record review showed that the resident had a remaining balance of $1,282.09 in the facility trust account at the time of death. Despite policy stating that a discharged or expired resident's trust account should be closed within 30 days, the funds were not conveyed to the resident's family within this timeframe. Documentation indicated that the business office manager (BOM) was aware of an overpayment from the Social Security Administration (SSA) and had made inquiries regarding the overpayment, but there was no documentation of communication with the SSA or the resident's family regarding the conveyance of the remaining funds. The resident involved had a diagnosis of dementia and was discharged from the facility after being sent to the emergency room, where they subsequently expired. Family members collected the resident's personal belongings, but the trust account balance remained unresolved. The BOM acknowledged attempts to address the SSA overpayment but lacked documentation of these efforts, and the administrator confirmed that funds are typically conveyed within 30 days, which did not occur in this case.
Unsecured Cleaning Chemical in Shower Room
Penalty
Summary
A deficiency was identified when cleaning chemicals were not properly secured in a shower room on the 400 hall. On two separate occasions, surveyors observed the shower room door ajar and unattended, despite the door being equipped with an automatic lock, passcode entry, and adequate spring tension to close. Inside the unsecured room, an opaque spray bottle labeled with "QUAT STAT 5" (a disinfectant) was found hanging from the whirlpool lift. The chemical's safety data sheet indicated it was a hazardous substance, requiring locked storage and warning of severe health risks upon contact. Interviews with the Director of Nursing (DON) and the administrator confirmed that facility policy required chemicals to be stored securely and inaccessible to residents. The administrator noted that the last safety check had been performed the previous month and acknowledged that the chemical would have been secured if the shower room door had been closed. No residents were observed wandering in the area at the time of the observations.
Failure to Obtain and Document Monthly Weights as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document monthly weights for a resident as ordered by the physician. The physician's order specified that the resident was to be weighed monthly, but a review of the electronic health record showed that the last recorded weight was in June, with no weights documented for July or August. The resident's care plan identified them as being at risk for weight fluctuations and required weights to be taken per physician orders and facility protocol. The resident was cognitively intact and had a diagnosis of depression. Interviews with staff revealed that both nurses and CNAs were responsible for obtaining and documenting weights, and the MDS coordinator was tasked with ensuring weights were obtained according to orders. The MDS coordinator was new to the position, and the DON stated that if the resident had refused to be weighed, a progress note should have been made, but no such documentation was found. The lack of documented weights or refusals for two consecutive months constituted a failure to follow physician orders and facility protocol.
Missing discharge summary for a resident's planned discharge
Penalty
Summary
The facility failed to ensure that a discharge summary with a recapitulation of the resident's stay was completed for Resident #99. Record review showed the resident had congestive heart failure, had a BIMS score of 13 indicating intact cognition, and had planned to return to the community with family. A physician order showed the resident was discharged with home health services, and a progress note documented that the resident discharged home with family with home health services. During interview, the DON stated that MDS coordinators usually completed discharge summaries and confirmed that a discharge summary with a recapitulation of the resident's stay had not been completed for the resident's planned discharge.
PASARR Recommendations Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to ensure that level 2 PASARR recommendations were incorporated into the plan of care for Resident #11. Record review showed the resident had psychiatric services visits on 03/01/25, 04/09/25, 07/09/25, and 08/13/25, and a PASARR meeting was completed on 01/17/25. The PASRR-MI Summary of Findings dated 01/18/25 recommended monthly psychiatric follow-up services and individual counseling/psychotherapy for 45 minutes weekly by a licensed mental health provider. A significant change assessment dated 08/19/25 showed the resident had a BIMS score of 13 and diagnoses of depression and psychotic disorder other than schizophrenia. The care plan updated 09/08/25 addressed a mood disorder with visual hallucinations and stated psychiatric services would evaluate and treat as indicated, but the electronic clinical record did not contain the level 2 PASARR. On 09/24/25, the administrator stated the facility had to call to obtain a copy of the level 2 PASARR because it was not in the facility or electronic record, and the quality manager nurse stated they had not received it. The care plan coordinator stated the recommendations had not been implemented because the level 2 PASARR had just been received earlier that day.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to the resident or resident representative for Resident #30, who was admitted to the facility and had a baseline care plan dated 11/15/24. The baseline care plan documented that a copy of the admission orders was given to the resident/resident representative and identified the resident's caregiver as the contact representative and emergency contact, but there was no documentation that the resident or resident representative received a summary of the baseline assessment/care plan or a copy of the medication administration record or treatment record. On 09/22/25, the MDS coordinator reviewed the clinical record and stated they did not see documentation that the resident or resident representative were given a copy of the baseline care plan. On 09/24/25, the DON reviewed the baseline care plan and the resident's clinical record and stated there was no documentation that the resident or resident representative were given a copy of the baseline care plan.
Care Plan Did Not Reflect Bed Rail Use
Penalty
Summary
The facility failed to ensure the care plan was revised to include the use of bed rails for Resident #11. On 09/17/25, a bed rail was observed on the right side of the resident’s bed in the up position. The resident’s significant change assessment dated 08/19/25 showed a BIMS score of 13, indicating the resident was cognitively intact for daily decision making, and listed a diagnosis of depression. However, the care plan updated 09/08/25 did not show that the resident used a bed rail on the right side of the bed. During record review and interview on 09/24/25, the quality manager nurse stated that because the resident used a bed rail, the care plan should have been revised, the MDS coordinator stated the bed rail had not been addressed in the care plan, and the DON stated the resident had used a bed rail for approximately 1.5 years but it had not been included in the resident’s care plan.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis because the facility failed to perform and document post-dialysis assessments. Resident #94 had a dialysis port on the right chest wall and an arteriovenous fistula for dialysis. The August 2025 treatment sheet included orders for dialysis every Tuesday, Thursday, and Saturday, weights on dialysis days, assessment of the fistula for thrill/bruit and signs of trauma or infection every shift, and restrictions against blood pressure, lab draws, or lifting with the arm containing the fistula and right arm due to the dialysis port. However, the September 2025 treatment sheet did not show these dialysis-related orders or assessment requirements. The MDS coordinator stated the floor nurse completed the pre-dialysis assessment form and sent it with the resident to dialysis, then typed the dialysis center’s written information into the electronic record when the resident returned. The coordinator also stated the post-dialysis vital signs entered into the pre/post dialysis assessment were obtained by the dialysis provider before the resident returned and did not automatically populate in the facility record, and the post-dialysis assessment was documented on the treatment record. After reviewing the chart, the coordinator stated they did not see where facility staff assessed the resident post dialysis. The DON later stated the resident had been hospitalized at the end of August, the admitting nurse failed to resume the dialysis-related orders, staff knew to perform the pre/post assessment but did not know the orders were not in place to document their findings, and the nurse documented the pre-dialysis assessment on a form that did not have space for the facility’s post assessment.
Missing assessment and consent for bed rail use
Penalty
Summary
The facility failed to ensure an assessment for the use of bed rails had been completed for Resident #11, who had a bed rail observed on the right side of the bed in the up position. The resident had a significant change assessment dated 08/19/25 showing a BIMS score of 13, indicating the resident was cognitively intact for daily decision making, and a diagnosis of depression. The care plan updated 09/08/25 did not show that the resident utilized a bed rail on the right side of the bed, and review of the electronic clinical record from 09/01/24 through 09/24/25 did not show an assessment for bed rail use or that consent had been obtained. Quality manager nurse #2 stated the facility did not have a policy for bed rails but was supposed to complete an assessment, obtain consent, obtain a physician order, update the care plan, and document a progress note; they also stated these steps had not been completed for Resident #11. The DON stated the resident had used a bed rail for approximately 1.5 years and that the record did not show an assessment, physician order, or consent for the bed rail.
Failure to Regularly Inspect Bed Rails
Penalty
Summary
The facility failed to ensure regular inspection of bed rails as part of its maintenance program for one resident who used a bed rail. On 09/17/25, a bed rail was observed on the right side of the resident’s bed in the up position. The resident’s significant change assessment dated 08/19/25 showed a BIMS score of 13, indicating the resident was cognitively intact for daily decision making, and listed a diagnosis of depression. During interviews on 09/24/25, the maintenance supervisor stated bed rails were applied to beds as indicated by the DON but were not regularly inspected after installation. The administrator stated the facility did not have a policy related to bed rails, bed safety, or inspection of resident beds, and that maintenance installed bed rails but did not regularly inspect them as part of the maintenance program. The administrator also stated the resident had an enabler bar and did not consider enabler bars to be bed rails. The DON stated the resident had utilized a bed rail for approximately 1.5 years.
Failure to Complete Resident Assessments on Time
Penalty
Summary
The facility failed to ensure resident assessments were completed within the required timeframe for 10 out of 11 residents whose transmission reports were reviewed. The CMS Transmission Report documented that several resident assessments, including quarterly, annual, admission, and end of skilled assessments, were completed more than 14 days after the assessment reference date. The MDS Coordinator reported that they were pulled to the floor to cover staffing, which prevented them from completing the resident assessments on time.
Failure to Change Oxygen and Humidifier Tubing Monthly
Penalty
Summary
The facility failed to ensure that oxygen and humidifier tubing was changed monthly for three residents with COPD. Resident #11 had oxygen tubing dated 02/13/24 and an empty humidifier dated 04/30/24, which was still in use on 05/28/24 and 05/29/24. Resident #40 had oxygen tubing dated 02/13/24 and an empty humidifier dated 04/10/24, which was still in use on 05/28/24 and 05/29/24. Resident #78 had oxygen tubing dated 02/13/24, which was still in use on 05/28/24 and was only changed on 05/28/24 after the surveyor's observation. The Director of Nursing (DON) acknowledged that the tubing should be changed at least monthly and admitted that the facility had issues with monitoring the changes. The facility's policy, last revised on 11/11/19, required that oxygen humidifiers and cannulas be changed monthly, but this was not adhered to for the three residents observed. The administrator identified six residents in total who require oxygen, indicating a broader issue with compliance to the policy.
Inadequate Staffing Leads to Missed Baths
Penalty
Summary
The facility failed to provide adequate staffing to ensure residents received their scheduled baths. Resident #34, diagnosed with end-stage renal disease and congestive heart failure, was scheduled to receive baths on Mondays and Wednesdays. However, documentation showed that Resident #34 missed several scheduled baths in May 2024, specifically on 05/08, 05/13, 05/22, and 05/27. Resident #34 reported not receiving a bath on 05/27 and mentioned that staff often cited insufficient staffing as the reason for not providing assistance with activities of daily living. Similarly, Resident #71, diagnosed with COPD, a history of falling, and a left hip replacement, was scheduled to receive baths on Wednesdays and Saturdays. Documentation revealed that Resident #71 missed scheduled baths on 05/11, 05/22, and 05/25. Resident #71 reported that it had been nearly two weeks since their last shower and attributed the missed baths to inadequate staffing. The Director of Nursing (DON) acknowledged the expectation for missed baths to be made up but admitted that the process for accounting and documenting baths was disorganized, failing to explain the lack of documented baths for Resident #71.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure a medication was administered as ordered for one of five sampled residents reviewed for medications. A physician's order dated February 8, 2024, documented that Levothyroxine Sodium Oral Tablet 88 MCG was to be administered once daily at 6:00 a.m. for hypothyroidism. However, the April 2024 Medication Administration Record (MAR) showed blanks for the 6:00 a.m. dose on multiple dates, indicating the medication was not given. Similarly, the May 2024 MAR also had blanks for the 6:00 a.m. dose on several dates. During an interview, a Certified Medication Aide (CMA) confirmed that blanks on the MAR meant the medication was not given and stated that the night shift nurse was responsible for administering the 6:00 a.m. medications.
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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) |
|---|---|---|---|---|
| Brentwood Extended Care & Rehab | 1.5 mi | ★★★★★ | 0 | 0 |
| Muskogee Nursing Center | 4.7 mi | ★★★★★ | 1 | 1 |
| Broadway Care & Rehab Center | 4.8 mi | ★★★★★ | 0 | 0 |
| Pleasant Valley Health Care Center | 5.1 mi | ★★★★★ | 0 | 0 |
| York Manor Nursing Home | 5.5 mi | ★★★★★ | 24 | 0 |
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