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 Oak Knoll Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with significant cognitive and physical impairments was transferred to the hospital for leg pain and swelling, where second-degree burns with blistering were discovered on both hands and the thigh. Facility staff failed to assess, document, or report these injuries prior to transfer, and no investigation was initiated as required by policy. The DON and administrator confirmed that staff did not follow procedures for reporting and investigating injuries of unknown origin.
A resident with severe cognitive impairment and behavioral symptoms was involved in a physical altercation with a housekeeper, during which the resident was reportedly hit in the face. Another resident witnessed the incident and eventually reported it to the receptionist. Several staff members observed or heard about the altercation but did not report it immediately, contrary to the facility's abuse and neglect policy requiring prompt reporting and investigation.
A CNA physically abused a resident with dementia and right-sided weakness by pulling the resident's hair multiple times after being struck during care. The incident, captured on video, occurred in the presence of other staff who did not intervene. The resident was dependent on staff for daily care and had a care plan requiring supportive interventions for distress, which were not followed. The abuse was not reported by staff at the time and was only discovered after another resident brought it to management's attention.
The facility failed to maintain complete and individualized care plans for several residents, omitting critical information such as the use of bed rails and code status. Observations showed discrepancies between the care plans and the actual needs of the residents, such as the presence of raised side rails not documented in the care plans. The Director of Nursing noted inconsistencies in the role of the MDS Coordinator, contributing to the lack of updated care plans.
The facility failed to assess and document the use of bed rails for several residents, contrary to its policy. Observations showed residents with cognitive impairments using bed rails without proper assessments or documentation in their care plans. Staff interviews revealed a lack of awareness regarding the need for assessments, with some believing side rails were standard with beds. The Administrator and DON acknowledged the need for assessments, but this was not consistently practiced.
The facility did not provide RN coverage for eight hours a day, seven days a week, despite having a census of 66 residents. The daily assignment sheets showed no RN scheduled on several dates. Interviews revealed that RN B worked part-time, and another RN worked every other weekend. The DON, who worked weekdays and weekends if needed, acknowledged she could not be considered a staff RN due to the census. The Administrator and DON agreed on the requirement for RN coverage.
The facility failed to maintain accurate records for controlled substances, with numerous blanks in the inventory logs from March to May 2024. The DON acknowledged that agency staff often neglected to sign the forms, which compromised the facility's ability to reconcile controlled substances accurately.
The facility failed to secure medication storage as required, with an LPN leaving the medication cart unlocked multiple times while administering medications, and the medication room door left open without supervision. Staff interviews confirmed that medication carts and rooms should be locked when unattended.
The facility did not maintain sanitary conditions in the kitchen by failing to label and date opened food items, including frozen meats and mixed fruit. This was observed during inspections, and both the Dietary Manager and DON confirmed the expectation for staff to label and date food. This issue had the potential to impact all 66 residents consuming food from the facility.
The facility failed to maintain complete and accurate medical records for several residents, resulting in numerous blank entries in the MAR/TAR for medications and treatments. This deficiency was observed across multiple residents with various medical conditions, and staff interviews confirmed that undocumented medications might not have been administered.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to Enhanced Barrier Precautions (EBP) by not wearing required PPE during high-contact activities with residents. Additionally, the facility did not implement a proper water management program to prevent the spread of pathogens like Legionella, lacking a water management team and a comprehensive understanding of the water systems.
The facility failed to conduct routine inspections of bed rails, leading to potential safety risks for several residents. Observations showed that side rails were used without proper assessments or documentation in medical records. Staff interviews revealed a lack of awareness and uncertainty about the use of side rails. The DON and Maintenance Director acknowledged the absence of routine maintenance checks, and the Administrator confirmed that assessments were not being conducted as required.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was sent to the hospital with swelling and pain in the left hip. The resident, who had diagnoses including Alzheimer's disease, hypertension, and pneumonia, required significant assistance with activities of daily living and had no documented open areas or bruises prior to the incident. Upon transfer to the hospital, staff there identified second-degree burns with blistering on both hands and the thigh, which had not been previously documented or reported by facility staff. Interviews revealed that the charge nurse on duty was focused on the resident's leg pain and swelling and did not assess or document the skin changes, specifically the blister on the left hand, which was only noticed by a CNA and an LPN as the resident was being transferred. Neither the charge nurse nor the LPN documented the blister or reported it to the Director of Nursing (DON). The DON, upon being notified by the hospital, stated she was unaware of how the burns occurred and had not interviewed nurse aides as part of the investigation, despite facility policy requiring comprehensive investigation and documentation of injuries of unknown origin. The administrator acknowledged that staff failed to report the skin changes prior to the resident's transfer, which prevented an investigation from being initiated. Facility policy required that all changes in a resident's condition, including skin injuries, be reported, assessed, documented, and investigated to determine the cause, but these steps were not followed in this case.
Failure to Protect Resident from Physical Abuse and Ensure Timely Reporting
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, schizophrenia, anxiety, and depression was involved in a physical altercation with a staff member. The resident, who had a history of verbal and physical behavioral symptoms, was reported to have been forcefully removed from a couch by a housekeeper. The resident did not recall the event and showed no physical injuries upon assessment, but later stated that the housekeeper hit them in the face near the left eye. Another resident, who had no cognitive impairment, witnessed the incident and reported seeing the housekeeper and the resident pushing each other, with the housekeeper hitting the resident in the eye. This witness was initially unsure about reporting the incident but eventually informed the receptionist. Additional staff interviews revealed that some staff heard or observed parts of the altercation but did not immediately report the incident, believing it had been resolved or that others would report it. The facility's abuse and neglect policy required immediate reporting and investigation of any suspected abuse. However, multiple staff members failed to report the incident promptly, and the housekeeper involved was later terminated for failing to report the altercation. The deficiency was identified through observation, interviews, and record review, confirming that the facility did not ensure the resident was free from physical abuse by a staff member.
Physical Abuse of Resident by CNA During Care
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) pulled a resident's hair multiple times while assisting the resident back to their room for hygiene care. The incident was captured on facility video footage, which showed the resident, who has dementia, right-sided weakness, aphasia, and other medical conditions, in a wheelchair in the dining room. After the resident struck the CNA in the face, the CNA followed and grabbed the resident's hair, with the action repeated two more times as the resident was pushed down the hallway. Two other staff members present did not intervene during the incident. The resident involved was dependent on staff for daily care due to cognitive loss and physical limitations, as documented in their care plan. The care plan specified that staff should provide assistance with transfers, toileting, bathing, and other care needs, and to use calming interventions if the resident showed signs of distress. Despite these directives, the CNA responded to the resident's behavior by physically grabbing the resident's hair, which constitutes physical abuse as defined by the facility's abuse/neglect policy. Interviews with staff present during the incident revealed that they did not witness or did not recall the altercation, and no immediate intervention was made to protect the resident. The CNA involved acknowledged that grabbing the resident's hair was wrong and stated it was a reaction to being scratched. The incident was not reported by staff at the time it occurred, and only came to management's attention after another resident reported it the following day.
Deficient Care Plans in LTC Facility
Penalty
Summary
The facility failed to ensure complete, accurate, and individualized care plans for five of the 18 sampled residents. The care plans did not address specific needs such as the use of bed rails and code status, which are critical for the safety and well-being of the residents. For instance, Resident #2's care plan did not include any information about the use of bed rails, despite observations showing the resident lying in bed with a quarter-length bed rail raised. Similarly, Resident #36's care plan lacked information regarding bed rails, even though observations noted the presence of raised side rails. Resident #34's care plan did not include information about the resident's code status, which is essential for emergency medical procedures. The facility's emergency medical procedures require that basic cardiac resuscitation be initiated in the event of a medical emergency, but the care plan did not reflect this information. Additionally, Resident #26's care plan did not address the use of side rails, despite observations of the resident lying in bed with side rails up. This lack of documentation and assessment poses a risk to the residents' safety and care. The Director of Nursing acknowledged that the MDS Coordinator was responsible for updating care plans, but there had been inconsistency in this role following the previous coordinator's departure. The care plans should reflect the residents' current needs, including the use of hospice, side rails, and other specific requirements. The facility's failure to maintain accurate and comprehensive care plans indicates a significant oversight in meeting the residents' needs and ensuring their safety.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that bed rails were accurately assessed as necessary devices prior to their installation and use for five of the 18 sampled residents. The facility's policy on the proper use of side rails, revised in October 2010, mandates that side rails should only be used to treat a resident's medical symptoms or assist with mobility and transfer. However, observations and interviews revealed that bed rails were used without proper assessments, documentation, or informed consent. For instance, Resident #62 had severe cognitive impairment and was observed with a U-shaped side rail raised, yet there was no documentation or assessment for its use in the care plan. Similarly, Resident #36, who also had severe cognitive impairment, was observed with quarter-length side rails raised on both sides of the bed without any physician's order or assessment documented. Resident #26, with severe cognitive impairment and schizophrenia, was observed with the top two quarter side rails up, despite the side rail use and risk assessment indicating no side rail was needed. These instances highlight a pattern of non-compliance with the facility's policy and federal regulations regarding the use of bed rails. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and responsibility for assessing the need for side rails. Some staff members believed that side rails were included with the beds and were used for positioning and turning, without recognizing the need for assessments or documentation. The Administrator and DON acknowledged that the use of side rails should be assessed by nursing staff before installation and included in the care plan, but this was not consistently practiced, leading to the deficiencies noted in the report.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, despite maintaining a census of 66 residents. Review of the facility's daily assignment sheets from 4/20/24 through 5/20/24 revealed that no RN was scheduled on multiple specific dates. Interviews with RN B and the Director of Nursing (DON) confirmed that RN B worked part-time on Tuesdays, Thursdays, and some weekends, while another RN worked every other weekend only. The DON, who worked Monday to Friday and weekends if needed, acknowledged that due to the facility's census, she could not be considered as a staff RN. The Administrator and DON agreed that the facility was required to have RN coverage for eight hours a day, seven days a week.
Deficiency in Controlled Substance Documentation
Penalty
Summary
The facility failed to establish a comprehensive system of records for controlled drugs, which is essential for accurate reconciliation. This deficiency was identified during an interview and record review, where it was found that the facility's controlled substance inventory records contained numerous blanks. These blanks indicated that the required documentation of controlled substance counts was not consistently completed. The facility's Controlled Substance Policy mandates that controlled substances must be counted upon delivery, with both the receiving nurse and the person delivering the medication order signing the designated narcotic record. However, the review of the inventory records from March to May 2024 showed multiple instances where the required signatures were missing, suggesting a lapse in adherence to the policy. During interviews, the Director of Nursing (DON) acknowledged that the controlled substances should be counted and documented by both the incoming and outgoing nurses at each shift change. The DON noted that the blanks in the inventory records were primarily due to agency staff failing to sign the forms. This oversight in documentation had the potential to affect all residents with controlled substance orders, as it compromised the facility's ability to accurately track and reconcile controlled substances, which is critical for ensuring the safety and proper management of medications for the residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely in accordance with professional principles. Observations revealed that a Licensed Practical Nurse (LPN) left the medication cart unlocked multiple times while administering medications to residents. The LPN walked away from the cart, leaving it unattended and unlocked, allowing residents to pass by it. This occurred on the 100 and 200 halls, with the LPN being away from the cart for several minutes at a time. Additionally, the medication room on the 200 hall was found to be left partially open without staff present at the nurse's station. A Registered Nurse (RN) also left the medication cart unlocked and unattended. During this time, a physical therapist entered the medication room unsupervised. Interviews with staff, including Certified Medication Technicians (CMTs) and the Director of Nursing (DON), confirmed that the medication carts and rooms should be locked when not in use, and only authorized staff should have access to the medication room.
Failure to Label and Date Opened Food in Kitchen
Penalty
Summary
The facility failed to maintain food under sanitary conditions by not ensuring that food was labeled and dated after being opened. This deficiency was observed during multiple inspections of the kitchen, where several opened and undated food items were found, including frozen hamburger, pork chops, hash browns, taco meat, buns, and bowls of mixed fruit covered with plastic wrap. The Dietary Manager and the Director of Nursing both acknowledged that the expectation was for staff to label and date food once the package had been opened. This oversight had the potential to affect all 66 residents who consumed food from the facility kitchen.
Incomplete Medication and Treatment Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for six residents, leading to a deficiency in maintaining medical records in accordance with accepted professional standards. The report highlights multiple instances where the Medication Administration Records (MAR) and Treatment Administration Records (TAR) contained blank entries, indicating that medications and treatments were either not administered or not documented properly. This issue was observed across several residents, each with specific medical conditions and treatment regimens that required precise documentation. For Resident #13, the MAR/TAR showed numerous blank entries for various medications and treatments, including nutritional supplements, iron tablets, anticonvulsants, and wound care treatments. Despite having a care plan that required specific interventions, the documentation was incomplete, with no explanations provided in the progress notes for the missing entries. Similarly, Resident #30's records showed blank entries for medications such as inhalers, anticonvulsants, and blood thinners, with only partial explanations in the progress notes for some of the missed documentation. Other residents, including Resident #26, Resident #2, Resident #51, and Resident #24, also had significant gaps in their MAR/TAR documentation. These residents had various diagnoses, including cognitive impairments, high blood pressure, schizophrenia, and Parkinson's disease, which necessitated consistent medication administration and documentation. The facility's failure to document these treatments accurately was confirmed through interviews with staff, who acknowledged that if a medication was not documented, it might not have been administered. The Director of Nursing and other administrative staff expressed their expectation for complete and accurate medical records, highlighting the deficiency in the facility's current practices.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to the Enhanced Barrier Precautions (EBP) policy during high-contact activities with residents. Specifically, staff did not wear the required personal protective equipment (PPE), such as gowns, when transferring residents with multidrug-resistant organisms (MDROs) or indwelling medical devices. For instance, two certified nurse aides (CNAs) were observed transferring a resident with a pressure ulcer without wearing gowns, despite the presence of an EBP sign on the resident's door. This oversight was repeated in another instance where a CNA failed to wear a gown while administering medications via a gastrostomy tube to a resident. Additionally, the facility did not properly implement its water management program to prevent the spread of waterborne pathogens like Legionella. Interviews revealed that the facility lacked a water management team, a water flow diagram, and a comprehensive understanding of the facility's water systems. The Maintenance Director was unaware of the potential respiratory infections caused by Legionella and did not have a structured approach to managing water safety, relying instead on monthly temperature checks and communication with the water company. The deficiencies in infection control practices and water management had the potential to affect all residents in the facility. The facility's Infection Preventionist and Director of Nursing acknowledged the importance of following infection control policies and procedures, including the need for a water system plan specific to the facility. However, the lack of adherence to established protocols and the absence of a structured water management program highlighted significant gaps in the facility's infection prevention efforts.
Failure to Conduct Routine Bed Rail Inspections
Penalty
Summary
The facility failed to ensure routine inspections of bed/side rails as part of a regular maintenance program, leading to potential safety risks for five residents. The facility's policy on the proper use of side rails, revised in October 2010, mandates that side rails should only be used to treat a resident's medical symptoms or assist with mobility and transfer. However, observations and interviews revealed that side rails were used without proper assessments or documentation in the medical records for several residents, including those with severe cognitive impairments and various medical conditions such as cancer, high blood pressure, and dementia. For Resident #62, observations showed a U-shaped side rail was used without a maintenance assessment, and staff interviews indicated a lack of awareness about the side rail's presence or use. Similarly, Resident #36 was observed with quarter-length side rails raised, but no maintenance assessment was documented. Resident #26, with severe cognitive impairment and schizophrenia, was also observed with side rails up, yet no maintenance assessment was found in the medical record. Resident #2, dependent on staff for all activities of daily living, had a bed rail raised without a physician's order or care plan direction, and staff interviews revealed uncertainty about the rail's use. The Director of Nursing and Maintenance Director acknowledged the lack of routine maintenance checks and assessments for side rails. The Maintenance Director admitted to only measuring the rails when initially installed and was unaware of a program to assess entrapment risks. The Administrator and DON confirmed that maintenance assessments for side rails were supposed to be conducted quarterly and as needed, but this was not being done, leading to the deficiency identified by the surveyors.
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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 Ferguson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Hills Care & Rehab Center | 0.7 mi | ★★★★★ | 28 | 0 |
| Heritage Care Center | 1.7 mi | ★★★★★ | 32 | 1 |
| Amberwood Estates Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 37 | 0 |
| Florissant Valley Health & Rehabilitation Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Estates Of St Louis, Llc, The | 2.7 mi | ★★★★★ | 3 | 0 |
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