Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Stigler Nursing & Rehab during CMS and state inspections, most recent first.
RN coverage was not maintained as required. PBJ staffing data showed no RN hours on several days, and the DON time logs did not document the DON working on those dates even though the DON stated they were the eight-hour-a-day RN coverage Monday through Friday. The facility had 54 residents, and the DON later stated they may have failed to sign the log when they worked those days.
Surveyors found that the facility did not maintain a clean environment when a room was observed with 3 to 4 inches of baseboard pulled away from the wall near the bathroom door and a moderate amount of black, mold-like substance on the wall under and around the baseboard. A housekeeper reported the black substance had been present for the entire three months they had worked there and that attempts to clean it had been unsuccessful. The maintenance supervisor also stated the substance looked like mold and acknowledged that spackling was used to reattach the baseboard and cover the area, which did not remove the suspected mold but only concealed it.
Advance directive information was not properly documented for two residents. One resident had a DNR order in the chart but no advance directive acknowledgement form was found, and another resident's acknowledgement form was incomplete and unsigned by the resident or resident representative. The administrator and SSD stated they could not locate signed advance directive documentation for either resident.
Failure to provide required Medicare beneficiary notices. A resident discharged from Part A skilled services and remaining in the facility was not issued a SNF ABN or NOMNC despite having benefit days remaining. Record review showed the resident did not receive either notice, and the MDS coordinator confirmed the notices were not provided as required.
Meal Transport Cross-Contamination During Service: Staff were observed transporting resident meals from the kitchen window without using a tray, handling drink glasses by the rims, and placing a dessert dish on a plate so it touched the food. The DM and DON stated the meal transport practices did not follow the facility's infection control policy, which prohibits touching eating surfaces of plates and rims of cups or glasses.
A resident with dementia, identified as at risk for elopement, managed to leave the facility without staff knowledge and was returned by a community member. Despite multiple indications of the resident's exit-seeking behavior, the facility failed to implement adequate monitoring or revise the care plan. Additionally, treatment carts were observed unlocked and unsupervised, indicating a lapse in safety protocols.
The facility did not maintain RN coverage for eight consecutive hours daily, as required. Timecards showed insufficient RN coverage on several dates, and a staff member confirmed the absence of an RN on two specific days, unaware that the RN was clocking out early.
A facility failed to create a comprehensive care plan for a resident with multiple pressure ulcers. The resident, who had conditions such as paraplegia and diabetes, had pressure ulcers on various parts of the body, but these were not included in the care plan. An LPN admitted to overlooking the wounds during an audit of new physician's orders.
A facility failed to ensure accurate wound care assessments for a resident with multiple wounds, including paraplegia and pressure ulcers. The resident's wounds were inaccurately documented as suspected deep tissue injuries (SDTI) instead of unstageable. An LPN noted the inaccuracies, and the facility had recently eliminated the dedicated wound care nurse position.
The facility failed to update the comprehensive care plans for four residents, leading to discrepancies between physician's orders and the care plans. Issues included unrecorded oxygen therapy, outdated shower schedules, missing CPAP documentation, and unupdated tube feeding orders.
A resident with dementia and other conditions was abused by a CNA who sprayed water in their face during a shower. The incident was reported but not investigated or notified to the state agency promptly. The abusive CNA was later rehired without proper screening, and the family expressed concerns about the rehiring.
The facility failed to provide hot water for approximately a month, affecting residents' ability to receive safe and comfortable care. Despite multiple repairs and the purchase of new commercial water heaters, the issue persisted, leading to cold shower temperatures and residents refusing to bathe.
The facility failed to ensure residents received scheduled bathing, affecting four residents who either required total assistance or supervision with ADLs. Issues with cold water and missing documentation were identified, with the COO acknowledging problems with the facility's water heaters.
The facility failed to report an abuse incident within the required two-hour timeframe and a final report within five days. A CNA reported another CNA for spraying a resident in the face with a shower nozzle, but the DON did not file a state reportable within the required timeframe, and the administrator only reported the incident nearly two months later. The abusive CNA was initially terminated but later seen working at the facility again.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a RN was present in the facility for at least eight consecutive hours a day, seven days a week during 08/2025 through 09/2025. A PBJ Staffing Data Report for 07/01/25 through 09/30/25 showed no RN hours on 08/25/25, 09/19/25, 09/24/25, and 09/25/25. The DON time logs for 08/2025 and 09/2025 did not show the DON worked on those dates, and the DON stated they were considered the eight-hour-a-day RN coverage Monday through Friday for the facility. The administrator identified 54 residents in the facility. On 02/11/26, the DON reviewed the time log and stated they must have failed to sign the log when they worked on those dates, and again stated they were considered the eight-hour-a-day RN coverage for those days.
Failure to Address Suspected Mold and Damaged Wall in Resident Room
Penalty
Summary
The facility failed to maintain a clean environment as part of its infection prevention and control program when surveyors observed a damaged wall and apparent mold-like substance in one resident room. During observation of room [ROOM NUMBER], 3 to 4 inches of baseboard were found pulled away from the bottom of the wall next to the bathroom door, with a moderate amount of black substance present on the wall under and around the baseboard. A housekeeper who had worked at the facility for three months stated the black substance looked like mold, reported it had been present the entire time they had worked there, and stated they had tried to clean it off several times but it would not come off. Later, the maintenance supervisor also stated the black substance looked like mold and explained that spackling had been used to adhere the baseboard back to the wall and around the skirting. The maintenance supervisor acknowledged that the spackling did not remove the suspected mold but only covered it up, and stated that the substance should have been cleaned off the wall. The report identifies 54 residents residing in the facility but does not provide specific medical histories or conditions for the resident(s) occupying the affected room.
Advance Directive Information Not Documented for Two Residents
Penalty
Summary
The facility failed to ensure residents were provided with advance directive information for 2 of 24 sampled residents reviewed for advance directives. A facility policy titled Health, Medical Condition and Treatment Options, Information Resident of, dated 12/2022, stated residents would be informed of their health, medical condition, and options for treatment and/or care, including the right to formulate an advance directive upon admission and/or if the resident requested to complete one after admission. For Resident #5, the electronic health record showed admission to the facility and a physician order indicating the resident's code status was do not resuscitate, but no advance directive acknowledgement form was located in the record. The administrator stated on interview that the signed acknowledgement form was not located and that advance directive information was provided and obtained with admission, but the form was not part of the clinical record. For Resident #10, an undated Advance Directive Acknowledgement form was present but was not marked to show whether the resident had executed an advance directive or had not executed one, and it did not have a signature by the resident or resident representative. The administrator and SSD stated they were unable to locate a signed copy of the advance directive or acknowledgement for this resident.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to ensure that residents discharged from Medicare Part A skilled services, who still had benefit days remaining and remained in the facility, were issued SNF ABN and NOMNC notices. Based on record review and interview, Resident #23 was admitted to Part A skilled services on 10/23/25, discharged from Part A skilled services on 12/19/26, and remained in the facility, but the SNF Beneficiary Notification Review form dated 02/10/26 showed the resident was not provided with either a SNF ABN or NOMNC notice. The MDS coordinator identified nine residents discharged from Medicare Part A skilled services with benefit days remaining in the past six months, and stated on 02/10/26 at 12:55 p.m. that SNF ABN and NOMNC notices were not provided to Resident #23 but should have been per regulations.
Meal Transport Cross-Contamination During Service
Penalty
Summary
The facility failed to ensure staff served food in a manner that would reduce the risk of cross contamination during meal service. During observation of kitchen meal distribution, CNA #1 obtained a resident meal from the kitchen window and carried an uncovered plate, dessert dish, and two drink glasses to the resident's table. CNA #1 handled the drink glasses by the rims while transporting them. CNA #2 also obtained a resident meal from the kitchen window and carried an uncovered plate with the dessert dish placed in the middle of the plate touching the food items, along with two drink glasses handled in part by the rim and bottom while transporting the meal to the resident's table. The facility's undated Food & Nutrition Infection Control policy stated not to touch eating surfaces of plates, inside of bowls, rims of cups or glasses, or food-contact ends of utensils, and not to stack bowls on cups or glasses. During interview, CNA #1 stated a tray should have been used to transport the meal and that the glasses should not have been handled by the rims. CNA #2 stated the dessert container should not have touched the food and identified it as an infection control concern. The DM and DON both stated staff should have used a tray and should not have handled the glasses by the rims or placed dessert containers on the plate touching the food.
Failure to Prevent Elopement and Secure Treatment Carts
Penalty
Summary
The facility failed to prevent the elopement of a resident diagnosed with dementia, who was identified as being at risk for elopement. The resident, who had a history of exit-seeking behavior, managed to leave the facility without staff knowledge and was returned by a community member. Despite multiple progress notes indicating the resident's attempts to leave the facility, the staff did not implement adequate monitoring or environmental interventions to prevent elopement. The care plan for the resident was not revised to address the risk, and there was no consistent plan in place to monitor and prevent further elopement. Additionally, the facility did not complete a baseline care plan for the resident upon admission, and the 72-hour portion of the wander risk assessment was incomplete. The facility's documentation was lacking, as evidenced by missing hourly resident check forms for several dates, indicating a failure to consistently monitor the resident. Observations revealed that the resident continued to wander the halls and approach the front door without staff intervention, further highlighting the lack of adequate supervision. Furthermore, the facility failed to ensure that treatment carts were locked and supervised. On multiple occasions, treatment carts were observed unlocked and unsupervised, posing a potential safety risk. Staff members acknowledged that the carts should be locked when not in use, but this practice was not consistently followed, indicating a lapse in adherence to safety protocols.
Removal Plan
- A notification sign will be placed on front door and service door to alert visitors and vendors to not let anyone out without notifying/asking facility staff first.
- All staff In-Serviced on elopement risk policy, ensuring that identified elopement risk residents are redirected away from doors, properly performing 1:1 monitoring, and location of list of wandering/elopement risk residents and to check list at beginning of shift.
- MDS Coordinator in-serviced on completion of care plans on all new admissions to include but not limited to potential for risk of elopement.
- HR/BOM in-serviced on all newly hired personnel will be educated on elopement policy, location of list of at risk for elopement residents with an acknowledgement page.
- Nursing Administration In-Serviced on reviewing elopement risk resident list/any new admissions and updating list accordingly during clinical meeting.
- DON/Designee will report any negative findings to QAPI.
- Any employee that can't be reached for In-Service will be inactive and taken off of schedule until education is provided.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required. A review of timecards from June 16, 2024, to July 31, 2024, revealed that RN coverage was not provided for the full eight hours on multiple dates, including June 16, June 17, June 28, July 2, July 3, July 4, July 10, July 13, July 17, July 18, July 27, and July 28, 2024. On August 1, 2024, at 1:15 p.m., a staff member acknowledged that there was no RN in the building on July 27 and July 28, 2024, and admitted to being unaware that the RN on shift was clocking out before completing the required eight hours.
Failure to Develop Comprehensive Care Plan for Resident with Wounds
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple wounds. The resident had diagnoses including paraplegia, end-stage renal disease, hepatitis C, diabetes, and pressure ulcers located on the coccyx, left heel, outer right ankle, outer right foot, and spinous process lower. Despite these conditions, the resident's care plan did not address the pressure ulcers. An LPN acknowledged missing the wounds during an audit of new physician's orders, indicating that the wounds should have been included in the care plan.
Inaccurate Wound Care Assessments
Penalty
Summary
The facility failed to ensure accurate wound care assessments for a resident with multiple wounds. The resident, who had diagnoses including paraplegia, end-stage renal disease, hepatitis C, diabetes, and pressure ulcers, was documented to have a suspected deep tissue injury (SDTI) on the spinous process lower and the coccyx. However, the wound care assessments were inaccurate regarding the staging of these wounds. An LPN reported that the wounds documented as SDTI should have been classified as unstageable. The facility had a dedicated wound care nurse, but the position was recently eliminated, which may have contributed to the inaccuracies in wound documentation.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update the comprehensive person-centered care plans to reflect the residents' current needs for four of the 15 sampled residents. Resident #2's care plan did not include oxygen therapy despite physician's orders and the resident's use of oxygen since 07/31/23. The MDS coordinator confirmed that the oxygen therapy was not captured on the MDS and was not included in the care plan. Resident #19's care plan was not updated to reflect the change in shower schedule, leading to the resident refusing showers due to the late timing. The MDS coordinator acknowledged that the care plan had not been updated to reflect the new shower schedule but stated it would be updated now. Resident #30's care plan did not document the use of a CPAP machine for sleep apnea, despite physician's orders and the resident's use of the machine. The MDS coordinator was unaware of the CPAP order and confirmed that it was not captured on the MDS or the care plan. Resident #46's care plan did not reflect the change from Osmolyte to Jevity for tube feeding, nor did it include the use of a protector around the G-tube site. The MDS coordinator and IP nurse both acknowledged that the care plan should have been updated with the new orders and the use of the protector but had not been done so.
Failure to Protect Resident from Abuse and Improper Rehiring of Abusive CNA
Penalty
Summary
The facility failed to ensure a resident was free from abuse, as evidenced by an incident involving a CNA who sprayed a resident in the face with water while the resident was screaming. The resident, who had diagnoses including dementia, major depression disorder, anxiety disorder, and cerebrovascular disease, was subjected to this abuse during a shower. The incident was witnessed by another CNA who reported it immediately to the DON. Despite the immediate termination of the abusive CNA, the facility did not conduct an investigation or notify the state agency until nearly two months later. Furthermore, the abusive CNA was rehired by the facility without proper screening or notification to the state agency. The administrator claimed to be unaware of the incident until it was reported to the state agency, and the DON admitted to not knowing the requirement to report abuse within two hours. The family member of the abused resident expressed concerns about the rehiring of the abusive CNA, especially given the CNA's pending charges for assault and battery in a separate incident. The facility's failure to promptly report the abuse and the rehiring of the abusive CNA without proper procedures highlight significant lapses in ensuring resident safety and compliance with regulatory requirements.
Failure to Provide Hot Water for Residents
Penalty
Summary
The facility failed to ensure hot water was provided for the residents for approximately a month. Multiple invoices document ongoing issues with the water heaters, including the replacement of various parts such as pipes, valves, thermostats, and connectors. Despite these efforts, the water heaters continued to malfunction, resulting in cold water temperatures in the showers. Observations confirmed shower temperatures as low as 90.3°F, and interviews with residents and staff corroborated the lack of hot water. One resident reported refusing to take showers due to the cold water, and another resident's representative stated that the resident had not been given a shower or bath in almost four weeks. The facility's Chief Operating Officer (COO) acknowledged the problem and mentioned that two new commercial water heaters had been purchased and were in the process of being installed. However, the installation was delayed due to the need for electrical upgrades. Maintenance staff confirmed that one water heater had been rewired and installed, and work was ongoing for the second unit. Despite these efforts, the deficiency persisted for an extended period, affecting the residents' ability to receive safe and comfortable care.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure residents received scheduled bathing for four residents sampled for activities of daily living (ADLs). Resident #1, who was severely cognitively impaired and required total assistance with ADLs, had no recent bathing documentation in their medical record. Resident #2, who was cognitively intact and independent with most ADLs, also had no recent bathing documentation. The resident reported refusing showers due to the water being ice cold, and a family member confirmed the resident had not been given a shower in almost four weeks. Resident #3, who had impaired cognition and required total assistance with bathing, similarly had no recent bathing documentation and reported not having showers as often as desired due to cold water. Resident #4, who was cognitively intact and required supervision with bathing, also had no recent bathing documentation in their medical record. The Chief Operating Officer (COO) acknowledged issues with the facility's water heaters, which were being replaced and rewired for commercial use. The Director of Nursing (DON) was unable to locate any bathing documentation for the four residents in question. The deficiency was further corroborated by interviews with the residents and their family members, who expressed concerns about the lack of proper bathing due to cold water. The maintenance staff confirmed that one water heater had been rewired and installed, while work on the second heater was ongoing. Despite these efforts, the lack of proper documentation and the residents' reports of inadequate bathing highlight a significant lapse in the facility's ability to provide essential care and assistance with ADLs as required.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to ensure all allegations of abuse were reported within the required two-hour timeframe and a final report within five days. Specifically, an incident involving a resident being sprayed in the face with a shower nozzle by a CNA was reported by another CNA to the charge nurse, ADON, and DON on the same day it occurred. However, the DON did not file a state reportable within the required two hours, and the administrator only faxed an incident report to the state agency nearly two months later. The DON admitted to not knowing about the two-hour reporting requirement, and the administrator claimed to have been unaware of the abuse until the later date when the report was finally filed. Additionally, the abusive CNA was initially terminated but was later seen working at the facility again, causing further concern among staff members who had reported the incident initially. The facility's policy on abuse and neglect requires the administrator to provide a written report of the results of all abuse investigations to the state survey and certification agency, local police department, and other relevant authorities within five working days of the reported incident. Despite this policy, the facility did not adhere to the required timelines for reporting the abuse incident involving the resident. The failure to report the abuse in a timely manner and the subsequent rehiring of the abusive CNA indicate significant lapses in the facility's adherence to its own policies and state regulations regarding abuse reporting and investigation.
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Illustrative
What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Stigler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Countryside Estates | 17.5 mi | ★★★★★ | 0 | 0 |
| Community Health Care Of Gore | 18 mi | ★★★★★ | 0 | 0 |
| Vian Nursing & Rehab, Llc | 18.6 mi | ★★★★★ | 0 | 0 |
| Sequoyah Manor, Llc | 24 mi | ★★★★★ | 1 | 0 |
| Eufaula Manor Nursing And Rehabilitation Center | 25.6 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.