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 Park Care Center during CMS and state inspections, most recent first.
The facility failed to store food safely, with multiple instances of improperly stored and undated food items observed in the kitchen and walk-in refrigerator. Interviews with the dietary manager and administrator confirmed that staff were expected to date and label opened food, but these expectations were not met, potentially affecting all 85 residents consuming food from the facility kitchen.
The facility failed to maintain an effective infection prevention and control program. Staff did not adhere to the Enhanced Barrier Precautions (EBP) policy, as they did not wear required PPE during high-contact activities with residents infected with MDROs. Additionally, a CNA did not follow the incontinent care policy, using improper techniques and failing to change gloves and perform hand hygiene. The facility also did not implement its water management program to prevent the spread of waterborne pathogens, lacking a detailed description or diagram of the water system.
The facility failed to maintain resident dignity by allowing a catheter bag to be visible from the hallway and by feeding a resident while standing. A resident with a catheter had their bag visible, which was bothersome to them, and another resident was fed by a CNA standing over them, leading to refusal to eat. Staff interviews confirmed that these practices do not align with maintaining resident dignity.
A resident with moderately impaired cognition and dependent on staff for transfers fell from their wheelchair in a transport van. The staff moved the resident without a nurse's assessment or calling 911, contrary to the facility's Fall Management Policy. The resident complained of pain, and a bandage was applied to a bleeding finger. The DON was informed via phone and instructed the staff to move the resident back into the chair, planning to assess them upon return to the facility.
The facility failed to properly label and store medications and biologicals, as observed in a nurse cart and a medication cart. An opened, undated, and unlabeled tube of Venelex ointment and Betamethasone cream were found, along with an opened Ensure Plus shake not refrigerated or labeled. The facility's policy requires proper labeling and storage, which was not followed.
A facility failed to administer prescribed water flushes and enteral nutrition for a resident dependent on a g-tube, leading to severe dehydration and hospitalization. Documentation showed multiple missed administrations, and family members confirmed the lack of water flushes. The facility's policies and protocols were not followed, contributing to the resident's deteriorating condition.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, which could potentially lead to cross-contamination. Observations in the kitchen revealed multiple instances of improperly stored food items. Inside the dry storage area, there were bags of cheesecake mix, yellow corn bread, fish breading, white rice, and all-purpose flour that were either opened, undated, or uncovered. Similarly, in the walk-in refrigerator, there were undated bags of orange and apple slices, sack lunches, and a large bag of lettuce that was partially uncovered and undated. These observations indicate a lack of adherence to the facility's food storage policy, which requires all leftovers to be labeled and dated with an expiration date of no more than three days. Interviews with the dietary manager and the administrator confirmed that the staff was expected to date and label opened food before placing it in the refrigerator and to ensure that opened packaging was covered and dated. However, the observations showed that these expectations were not met, as evidenced by the undated and improperly stored food items. The facility's failure to comply with its own food storage policy had the potential to affect all residents consuming food from the facility kitchen, given the facility's census of 85 residents.
Infection Control Deficiencies in PPE Use and Water Management
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. Staff members did not wear the required personal protective equipment (PPE), such as gowns, during high-contact activities with residents infected with multidrug-resistant organisms (MDROs). Specifically, a Licensed Practical Nurse (LPN) did not wear a gown while administering medication via a feeding tube to a resident on EBP. Additionally, Certified Nurse Aides (CNAs) failed to wear gowns while providing perineal care to another resident, despite the presence of signage indicating the need for EBP. The facility also did not follow its incontinent care policy during the provision of perineal care to a resident. A CNA used a bath towel instead of washcloths or disposable wipes, as specified in the policy, and failed to change gloves and perform hand hygiene between handling clean and dirty items. This improper technique was observed during the care of a resident who was frequently incontinent and dependent on staff for personal hygiene. The CNA's actions were inconsistent with the facility's procedures for maintaining infection control during perineal care. Furthermore, the facility did not implement its water management program to prevent the spread of waterborne pathogens, such as Legionella. The Administrator admitted to not having a detailed description or diagram of the facility's water system, which is a critical component of the water management policy. This oversight had the potential to affect all residents in the facility, as it compromised the facility's ability to detect and control water-borne contaminants effectively.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of residents by allowing a catheter bag to be visible from the hallway and by feeding a resident while standing. Resident #90, who has mild cognitive impairment and uses an indwelling urinary catheter, was observed with their catheter bag visible from the doorway on multiple occasions. The resident indicated that the visibility of the catheter bag was bothersome. Interviews with staff, including a CNA, LPN, and the Administrator, confirmed that catheter bags should be covered to maintain resident dignity. Additionally, Resident #43, who is cognitively impaired and requires substantial assistance with eating, was observed being fed by a CNA who stood over them during the meal. The resident refused to eat when fed in this manner. Interviews with another CNA, an RN, and the Administrator and DON confirmed that staff are expected to be at eye-level with residents when assisting with eating to maintain dignity.
Failure to Follow Fall Management Policy During Transport
Penalty
Summary
The facility failed to adhere to its Fall Management Policy when a resident fell on the facility's transport van while returning from a doctor's appointment. The resident, who had moderately impaired cognition and was dependent on staff for transfers, slipped out of their wheelchair when the van stopped at a stop sign. Despite the resident's complaints of sliding, the staff did not take immediate action to secure the resident properly. The resident's wheelchair was secured, but the resident only used a waist strap due to their size, which allowed them to slip under the seat belt. After the fall, the staff, including the transportation specialists and a CNA, moved the resident back into the wheelchair without a nurse's physical assessment or calling 911, contrary to the facility's policy. The resident complained of pain in their right finger, which was bleeding, and a bandage was applied. The staff did not notify the facility immediately, and the DON was only informed via a phone call. The DON instructed the staff to move the resident back into the chair and stated she would assess the resident upon their return to the facility. The incident highlighted a failure to follow the facility's policy, which required a nurse to evaluate the resident for injury before moving them or to call 911 if necessary. The DON expected the same fall policy to be followed off-site as on-site, which was not adhered to in this case. The staff's actions were based on the assumption that the resident had not hit their head and that the proximity to the facility was close enough to wait for an assessment upon return.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an observation of the nurse cart for Halls 100 and 200, it was found that a tube of Venelex ointment and a tube of Betamethasone cream were opened, undated, and unlabeled with the resident's name. A Certified Medication Technician (CMT) confirmed that opened containers of medications should be dated once opened and that undated medications should be discarded. Additionally, a carton of Ensure Plus nutrition shake was found opened, undated, and unlabeled in the medication cart for Hall 200. The carton was half full, not refrigerated or iced, and placed in the medication cart drawer. The CMT was unaware of when the shake was opened. The facility's Medication Storage Policy requires that medications and biologicals be stored safely and securely, and that opened medications be dated and labeled. The Administrator and Director of Nursing stated that they expected staff to follow this policy.
Failure to Administer Prescribed Water Flushes and Enteral Nutrition
Penalty
Summary
The facility failed to provide appropriate administration of water flushes and enteral nutrition for a resident dependent on a gastrostomy tube (g-tube) for nutrition and hydration. The resident was admitted with orders for continuous Nepro feeding and water flushes every four hours. However, documentation showed multiple instances where the facility did not administer the prescribed water flushes and tube feeding as ordered. This failure was evident in the Medication Administration Record (MAR), which had several blanks indicating missed administrations. The resident's condition deteriorated, leading to hospitalization where they were diagnosed with metabolic encephalopathy, uremia, and hypernatremia. Interviews with staff and family members revealed that the resident was not receiving the required water flushes, and the facility's documentation practices were inconsistent. The family, who visited daily, confirmed that they did not observe the resident receiving water flushes as ordered, except on the day the resident was sent to the hospital. The facility's policies and protocols for medication administration and tube feeding management were not followed. The Director of Nursing (DON) and other staff members acknowledged the lapses in documentation and administration. The Registered Dietician (RD) was not informed of the resident's admission in a timely manner, delaying the nutritional assessment. The facility's failure to adhere to prescribed orders and accurately document care contributed to the resident's severe dehydration and subsequent hospitalization.
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Illustrative
What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delhaven Manor | 1.9 mi | ★★★★★ | 1 | 0 |
| Monarch Springs Wellness & Rehabilitation | 2.1 mi | ★★★★★ | 3 | 0 |
| Bernard Care Center | 2.6 mi | ★★★★★ | 31 | 0 |
| Lutheran Convalescent Home | 2.7 mi | ★★★★★ | 0 | 0 |
| Barnes-jewish Extended Care | 2.7 mi | ★★★★★ | 15 | 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.