Inspection Reports for
Armour Oaks Senior Living Community

The visit was complaint-related due to allegations of misappropriation of controlled substances by RN A. The complaint was substantiated as RN A was found to have signed out additional narcotic doses without proper documentation or administration. RN A was suspended, drug tested, and terminated. Law enforcement was notified and investigation remained open as of 6/3/25.

The facility failed to prevent misappropriation of controlled substances involving RN A, who signed out additional doses of narcotics without proper documentation or administration records. RN A was suspended and terminated following the investigation. Training was conducted for all nursing staff on abuse, neglect, and controlled substance administration. No residents were reported to have been harmed or overdosed.

The facility failed to maintain hot water temperatures consistently between 105°F and 120°F, with some resident rooms having water temperatures as low as 76.1°F and others exceeding 120°F. Staff also failed to allow water to flow for at least two minutes before measuring temperatures, potentially affecting all residents.

The complaint involved an allegation by Resident #30 that CMT B physically and verbally abused him/her on 1/1/24. The facility delayed reporting the allegation until 1/8/24. The investigation included interviews with the resident, staff, and witnesses. The facility could not substantiate the abuse due to lack of evidence and conflicting accounts. CMT B was suspended and later terminated for other reasons.

The facility failed to report the abuse allegation immediately, starting the investigation seven days after the incident. The investigation could not substantiate the abuse due to conflicting statements and lack of witnesses. CMT B was suspended pending investigation and later terminated for unrelated performance issues. Staff were educated on abuse reporting and resident dignity.

The complaint investigation was triggered by an allegation of physical and verbal abuse by Certified Medication Technician (CMT) B against Resident #30 on 1/1/24. The facility delayed reporting and investigation of the allegation. The investigation could not substantiate the abuse due to conflicting statements and lack of witnesses. CMT B was suspended and later terminated for unrelated issues. Staff were educated on abuse reporting requirements.

The facility failed to report an allegation of abuse immediately and delayed investigation by seven days. The resident reported physical and verbal abuse by Certified Medication Technician (CMT) B. The facility could not substantiate the abuse due to lack of witnesses and conflicting statements. CMT B was suspended pending investigation and later terminated for unrelated performance issues. Staff were educated on abuse reporting. Additional findings included failure to notify the Ombudsman of resident transfers, inaccurate Minimum Data Set (MDS) submissions, incomplete care plans, medication administration issues, inadequate supervision for elopement risk, food safety violations, and deficiencies in infection control and water management programs.

The complaint was substantiated as the resident reported CNA B was rough, grabbed his/her arm hard, and caused pain and bruising. Multiple staff interviews and assessments confirmed the incident. The resident was scared and did not want CNA B to care for him/her again. CNA B denied rough handling but acknowledged pulling the resident up in bed. The Director of Nursing and Administrator were involved in education and follow-up.

The facility failed to ensure the resident was free from accidental injury when CNA B grabbed and turned the resident without communication, causing a bruise. The resident was cognitively intact and required extensive assistance. The facility provided education to CNA B after the incident. The injury was minimal harm with few residents affected.

The facility was found deficient in multiple areas including failure to protect residents' property from loss or theft, failure to protect residents from misappropriation of property, failure to timely report suspected abuse and misappropriation, failure to provide baseline care plans to residents or their representatives, failure to provide adequate oral care and hydration, failure to properly investigate and document resident falls, failure to maintain safe respiratory care equipment, failure to maintain adequate RN staffing, failure to properly label and store medications, failure to maintain food safety and sanitation in the kitchen, and failure to implement a comprehensive infection prevention and control program including tuberculosis screening and waterborne pathogen prevention.

The facility was found deficient in multiple areas including failure to maintain a clean and odor-free environment, incomplete and untimely employee background checks, medication administration errors, failure to follow physician orders, inadequate infection control practices, improper storage and labeling of medications, unsafe food handling and storage practices, incomplete fall investigations, and maintenance issues such as damaged equipment and facility cleanliness.