Deficiencies (last 8 years)
Deficiencies (over 8 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
205% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
92% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Date: May 28, 2025
Visit Reason
The inspection was conducted due to a complaint and investigation regarding misappropriation of controlled substances by a Registered Nurse (RN A) who repeatedly signed out duplicate doses of narcotics for three sampled residents.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to prevent misappropriation of controlled substances by RN A signing out duplicate narcotic doses without proper documentation.
Report Facts
Residents census: 100
Medication doses signed out by RN A: 6
Medication tablets in bubble pack: 45
Medication tablets remaining: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings for misappropriation of controlled substances and medication errors |
| LPN A | Licensed Practical Nurse, Clinical Coordinator | Reported medication error and participated in controlled substance counts |
| LPN B | Licensed Practical Nurse | Participated in controlled substance counts and reported discrepancies |
| DON | Director of Nursing | Conducted investigation and audits of controlled substances |
| Administrator | Facility Administrator | Informed of controlled substance discrepancy and oversaw investigation |
| Physician | Notified of medication discrepancy and provided clinical input |
Inspection Report
Routine
Census: 35
Deficiencies: 2
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with safe water temperature regulations in the nursing home, following concerns about inconsistent hot water temperatures throughout the facility.
Findings
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.
Deficiencies (2)
Failure to ensure hot water temperatures were consistently between 105°F and 120°F in resident rooms.
Failure to ensure staff allowed water to flow for at least two minutes before measuring water temperatures.
Report Facts
Water temperature readings: 76.1
Water temperature readings: 121.4
Facility census: 35
Hot water heater temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant | Provided information about water heater and mixing valve system during interview | |
| Administrator | Provided information about water temperature issues and resident incident during interview | |
| Maintenance Person | Discussed confusion about water temperature regulation and measurement methods during interview |
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 3
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with environmental conditions related to hot water temperatures in the facility.
Findings
The facility failed to maintain safe and consistent hot water temperatures in multiple resident rooms, with temperatures ranging outside the required 105°F to 120°F range. Staff were also not ensuring proper procedures for measuring water temperatures.
Deficiencies (3)
F921: The facility failed to ensure hot water temperatures were consistently maintained between 105°F and 120°F in resident rooms, with some rooms having temperatures as low as 76.1°F and others exceeding 121°F. Staff did not allow water to flow for at least 2 minutes before measuring temperatures, potentially affecting all residents.
A3023: The facility did not ensure plumbing fixtures supplying hot water were thermostatically controlled to maintain water temperature between 105°F and 120°F, violating state regulation 19 CSR 30-85.032(24).
A6025: Plumbing was not sized, installed, and maintained according to the National Plumbing Code, violating 19 CSR 30-87.020(25).
Report Facts
Facility census: 35
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 4
Date: Feb 8, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to fire safety, smoking regulations, oxygen storage, and heating appliances at Armour Oaks Senior Living Community.
Findings
The facility failed to ensure proper fire-rated smoke partitions, prevent smoking in non-designated areas, ensure oxygen storage compliance, and prohibit the use of portable space heaters. These deficiencies potentially affected all 37 residents present during the inspection.
Deficiencies (4)
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to ensure all smoke stop partition doors properly closed during a fire alarm. The facility census was 37.
19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised. The facility failed to prevent smoking in non-designated smoking areas. The facility census was 37.
19 CSR 30-86.022(17) Oxygen Storage Requirements. The facility failed to ensure oxygen storage in a resident's room was in accordance with NFPA 99, 1999 Edition. The facility census was 37.
19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable. The facility failed to ensure the use of portable space heaters was prohibited. The facility census was 37.
Report Facts
Facility census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Isaac Smith | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Jan 16, 2024
Visit Reason
The investigation was conducted due to an allegation of physical and verbal abuse by Certified Medication Technician (CMT) B towards Resident #30 on 1/1/24, which was reported late to the administration and required a facility investigation.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to timely report suspected abuse to administration and proper authorities.
Report Facts
Residents present: 34
Days delay in reporting abuse: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medication Technician | Alleged perpetrator of abuse, suspended pending investigation |
| LPN B | Licensed Practical Nurse | Reported abuse allegation to MDS Coordinator and interviewed resident |
| RN A | Registered Nurse | Witnessed yelling, de-escalated situation, failed to report incident timely |
| Administrator | Facility Administrator | Interviewed regarding incident and facility response |
| DON | Director of Nursing | Provided staff education and oversight on abuse and dignity issues |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 11
Date: Jan 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of abuse involving Resident #30 and concerns about timely reporting and investigation of the incident.
Complaint Details
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.
Findings
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.
Deficiencies (11)
Failure to timely report and investigate an allegation of abuse involving Resident #30 and CMT B.
Failure to provide timely notification to the Ombudsman for resident transfers and discharges.
Failure to submit a resident's discharge assessment to CMS as required.
Failure to ensure accuracy of Minimum Data Set (MDS) assessments for residents #19, #31, and #3.
Failure to develop a comprehensive care plan including anticoagulant medication for Resident #31.
Failure to prime insulin pen prior to administration and failure to ensure medications were not left at bedside for Resident #23 and Resident #25.
Failure to provide adequate supervision to prevent elopement of Resident #335 and failure to complete quarterly Safe Smoking Assessments for Resident #20.
Failure to maintain food safety standards including cleanliness, temperature control, and equipment maintenance in the kitchen.
Failure to establish and maintain a comprehensive infection prevention and control program addressing water-borne pathogens.
Failure to respond to pharmacist's recommendations and ensure adequate monitoring parameters for medications for Resident #31.
Failure to monitor target behaviors and side effects for psychotropic medications for Resident #31.
Report Facts
Residents affected: 34
Deficiencies cited: 11
Resident #30 census: 34
Resident #31 blood pressure: 70
Resident #31 blood pressure: 51
Resident #31 blood pressure: 103
Resident #31 blood pressure: 59
Resident #31 blood pressure: 93
Resident #31 blood pressure: 56
Resident #335 elopement duration: 20
Temperature: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medication Technician | Named in abuse allegation and investigation |
| LPN B | Licensed Practical Nurse | Reported abuse allegation and interviewed during investigation |
| RN A | Registered Nurse | Witnessed resident yelling and involved in abuse investigation |
| DON | Director of Nursing | Provided education on abuse reporting and interviewed regarding multiple findings |
| Administrator | Facility Administrator | Interviewed regarding abuse allegation, elopement, and facility policies |
| CNA A | Certified Nursing Assistant | Witnessed resident behaviors and involved in elopement incident |
| Dietary Aide A | Dietary Aide | Involved in resident elopement incident |
| MDS Coordinator | Interviewed regarding MDS accuracy and submission | |
| Assistant Plant Operations Director | Involved in resident elopement recovery | |
| Operations Director | Responsible for water management program | |
| Dietary Manager | Interviewed regarding kitchen sanitation and elopement communication |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Jun 29, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that a Certified Nursing Assistant (CNA B) was rough with a resident (Resident #1), causing a bruise on the resident's inner left forearm during care.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure one sampled resident was free from accidental injury when CNA B left a bruise on the resident's inner left forearm during care.
Report Facts
Residents present: 37
Date of incident: Jun 25, 2023
Date of resident MDS assessment: Jun 2, 2023
Date of resident nursing care plan: Jun 9, 2023
Date of hospice admission: May 19, 2023
Date of CNA B education: Jun 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in the finding related to rough handling and causing injury to Resident #1 |
| Director of Nursing | Director of Nursing (DON) | Conducted education for CNA B and assessed the resident post-incident |
| CNA A | Certified Nursing Assistant | Reported the incident to charge nurse after resident complaint |
| RN A | Registered Nurse | Charge nurse on duty who assessed resident and notified DON of the allegation |
| Facility Physician | Physician | Interviewed regarding the incident and resident condition |
| Facility Administrator | Administrator | Interviewed regarding staff orientation and incident follow-up |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to investigate a deficiency related to accident hazards, supervision, and devices at Armour Oaks Senior Living Community.
Findings
The facility failed to ensure one resident was free from accidental injury caused by a Certified Nursing Assistant. The resident had a bruise on the inner left forearm, and the facility staff did not provide adequate supervision or assistance to prevent the injury.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure one resident was free from accidental injury when a Certified Nursing Assistant left a bruise on the resident's inner left forearm. The resident required extensive assistance and supervision which was not adequately provided.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as referenced in F689.
Report Facts
Facility census: 37
Sampled residents: 3
Refresher education audit sample: 3
Monthly audit sample: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| CNA B | Certified Nursing Assistant involved in resident injury incident | |
| Director of Nursing | Director of Nursing (DON) | Involved in investigation, education, and confirmation of corrective actions |
| CNA A | Reported CNA B's rough handling of resident | |
| RN A | Registered Nurse | Charge nurse on duty who assessed resident injuries and notified DON |
Inspection Report
Routine
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
Annual inspection survey of Armour Oaks Senior Living Community to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Feb 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of improper resident handling and potential abuse by a Certified Nursing Assistant (CNA) at Armour Oaks Senior Living Community.
Complaint Details
The complaint investigation was substantiated. The CNA was suspended and later terminated for poor customer care and failure to follow safe resident handling procedures. Interviews and record reviews confirmed the resident was cognitively intact but was hurt during transfers due to improper use of gait belts and lack of staff training.
Findings
The facility failed to ensure staff safely transferred two sampled residents and did not provide timely training on the use of gait belts and safe resident handling. One CNA was terminated for poor customer care and failure to follow safe handling guidelines. The facility lacked consistent staff training and availability of gait belts for transfers.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff safely transferred two sampled residents and did not provide consistent training on gait belt use and safe resident handling. Gait belts were not always available and staff did not consistently use them during transfers.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the issues noted in F689.
Report Facts
Facility census: 38
Dates of resident admission: Resident #1 admitted 5/13/21, Resident #6 admitted 10/26/23
Dates of training and emails: Emails from DON on 2/14/23 and 2/15/23 regarding CNA training status
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Smith | Administrator | Signed the inspection report and plan of correction |
| CNA A | Named in findings for improper resident handling and terminated | |
| Director of Nursing | DON | Involved in investigation, training, and plan of correction |
| CNA D | Observed placing gait belt and assisting resident during transfer | |
| CNA E | Observed holding resident's arm during transfer | |
| LPN B | Licensed Practical Nurse | Interviewed about gait belt use expectations |
| LPN A | Licensed Practical Nurse | Interviewed about gait belt use expectations |
| RN A | Registered Nurse | Interviewed about gait belt use expectations |
| Physician A | Physician | Interviewed about expectations for staff during resident transfers |
Inspection Report
Life Safety
Census: 33
Capacity: 37
Deficiencies: 4
Date: Oct 13, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations for Armour Oaks Senior Living Community.
Findings
The facility failed to maintain emergency lighting with battery backup and failed to maintain their generator according to NFPA standards. Observations included lack of required emergency lighting tests and unsafe generator conditions such as accumulation of combustible debris and use of extension cords and heat lamps.
Deficiencies (4)
K291 Emergency Lighting: The facility failed to maintain emergency lights with battery backup and did not perform required monthly and annual tests. The facility had a capacity of 37 with a census of 33 at the time of the survey.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain their generator according to NFPA standards, including unsafe conditions such as combustible debris accumulation and use of extension cords and heat lamps in the generator.
A2050 Emergency Lighting: Facilities shall have emergency lighting of sufficient intensity with automatic transfer switch and battery backup. This regulation was not met as referenced by K218.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment must be installed and maintained per NFPA 70. This regulation was not met as referenced by K918.
Report Facts
Facility capacity: 37
Census: 33
Inspection Report
Routine
Census: 37
Capacity: 38
Deficiencies: 11
Date: Jul 20, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with health and safety standards, including resident rights, medication management, infection control, and facility safety.
Findings
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.
Deficiencies (11)
Failure to document personal belongings upon admission and timely follow-up on grievances related to missing clothes for multiple residents.
Failure to protect a resident from misappropriation of property when unauthorized charges were made on the resident's debit card.
Failure to timely report suspected abuse and misappropriation to the State and local Police within 24 hours.
Failure to provide residents or their representatives with a written summary of the baseline care plan within 48 hours of admission.
Failure to provide daily oral care including teeth brushing and fresh water daily to residents.
Failure to follow fall monitoring policy including incomplete fall investigation documentation, lack of neurological checks, failure to update care plans post-fall, and inadequate notifications.
Failure to store nebulizer mask in a bag when not in use as per facility policy.
Failure to have a Registered Nurse on duty eight hours a day, seven days a week.
Failure to ensure medications are labeled with opened dates, medication containers are clean, and residents' personal belongings are not mixed with medications.
Failure to maintain kitchen and food storage areas in a sanitary condition, including clean floors, operable thermometers, sanitary utensils, proper hair hygiene, and separation of damaged foodstuffs.
Failure to implement a comprehensive infection prevention and control program including tuberculosis screening and waterborne pathogen prevention.
Report Facts
Residents census: 37
Total licensed capacity: 38
Unauthorized debit card charges: 303.69
Number of falls for Resident #30: 6
Fall risk score: 14
Fall risk score: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Mentioned in relation to missing clothes and nebulizer treatment |
| Licensed Practical Nurse A | Licensed Practical Nurse | Mentioned in relation to missing clothes, nebulizer treatment, and fall interventions |
| Administrator | Mentioned in relation to investigations, staffing, and policy enforcement | |
| Director of Nursing | Director of Nursing | Mentioned in relation to investigations, staffing, and policy enforcement |
| Social Service Designee | Mentioned in relation to grievance process and missing items | |
| Certified Nursing Assistant A | Certified Nursing Assistant | Mentioned in relation to oral care and fall interventions |
| Certified Nursing Assistant B | Certified Nursing Assistant | Mentioned in relation to oral care and missing items |
| Licensed Practical Nurse B | Licensed Practical Nurse | Mentioned in relation to medication cart cleanliness |
| Certified Nursing Assistant C | Certified Nursing Assistant | Mentioned in relation to staffing schedules |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 6
Date: Sep 30, 2021
Visit Reason
The inspection was conducted due to allegations of misappropriation and diversion of controlled substances involving Resident #1, triggered by a complaint or investigation of possible drug diversion and abuse.
Complaint Details
The investigation was substantiated. The facility census was 27 residents. The complaint involved allegations of drug diversion and misappropriation of controlled substances for Resident #1. The facility failed to report the alleged violations timely to the state agency and law enforcement.
Findings
The facility failed to ensure Resident #1 was free from misappropriation and exploitation related to controlled substances. Evidence showed tampering with morphine bottles and discrepancies in medication counts, indicating possible drug diversion. The facility also failed to report alleged violations timely to appropriate authorities.
Deficiencies (6)
F602: The facility failed to ensure Resident #1 was free from misappropriation and exploitation of controlled substances, evidenced by tampered morphine bottles and discrepancies in medication counts.
F609: The facility failed to report alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property within required timeframes to the administrator and other officials.
F761: The facility failed to maintain accurate counts of controlled medications stored in locked compartments, resulting in discrepancies and potential drug diversion.
A4070: The facility failed to establish a system of records for receipt and disposition of controlled drugs to enable accurate reconciliation, evidenced by tampered morphine bottles.
A8023: The facility failed to develop and implement written policies prohibiting abuse, neglect, and misappropriation of resident property and to report suspected abuse promptly.
A8024: The facility failed to ensure all staff were trained on laws and rules regarding reporting suspected abuse and neglect of residents.
Report Facts
Facility census: 27
Medication count discrepancy: 24
Medication count discrepancy: 30
Plan of correction completion date: Corrective actions to be completed by 2021-11-12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Involved in medication count and discrepancy findings |
| LPN B | Licensed Practical Nurse | Involved in medication count and discrepancy findings |
| RN A | Registered Nurse | Involved in medication wastage and count discrepancies |
| RN B | Registered Nurse | Involved in medication count and discrepancy findings |
| RN C | Registered Nurse | Involved in medication count and discrepancy findings |
| DON | Director of Nursing | Notified of discrepancies and involved in investigation |
| ADON | Assistant Director of Nursing | Discovered tampered morphine bottles and notified DON |
| Pharmacist | Provided information about medication shipments and tampering |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 20, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Sep 11, 2020
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to maintain comfortable and safe temperature levels for residents.
Complaint Details
Complaint MO 00175242 regarding inadequate heating and cold temperatures in resident rooms.
Findings
The facility failed to ensure a comfortable and homelike environment for five sampled residents, with temperatures in resident rooms and common areas consistently below the required 71 degrees Fahrenheit. Multiple residents complained of being cold, and observations confirmed temperatures below regulatory standards.
Deficiencies (2)
F584 Safe Environment: The facility did not maintain comfortable and safe temperature levels, with temperatures below 71 degrees Fahrenheit in multiple resident rooms and common areas. Residents reported feeling cold and discomfort due to inadequate heating.
A3028 Heating System 68-86 Degrees: The facility failed to heat all resident-accessible areas to at least 68 degrees Fahrenheit, with temperatures below the required minimum. This deficiency was linked to the complaint and referenced F584.
Report Facts
Facility census: 36
Temperature readings: 66.5
Temperature readings: 67
Plan of Correction completion date: Oct 28, 2020
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 3
Date: Sep 11, 2020
Visit Reason
The document is a Plan of Correction submitted by Armour Oaks Senior Living Community following a survey conducted on September 11, 2020, addressing deficiencies related to emergency preparedness and climate control policies.
Findings
The facility failed to maintain required temperature ranges during a climate control outage, potentially affecting resident safety. Policies and procedures for emergency preparedness and staff training were also found deficient.
Deficiencies (3)
E015: The facility failed to maintain temperatures within the required range of 71°F to 81°F during a climate control outage, affecting resident safety. The facility also lacked adequate policies and procedures for emergency preparedness including alternate energy sources and staff training.
A4013: The facility did not develop adequate policies and procedures to ensure residents' health and safety, including emergency treatment and disaster prevention. This deficiency is linked to E015.
A4015: Personnel were not fully informed of the facility's policies and their duties, related to emergency preparedness. This deficiency is linked to E015.
Report Facts
Facility census: 36
Temperature range: 71
Temperature range: 81
Plan of Correction completion date: October 26, 2020
Inspection Report
Routine
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/21/20 to assess compliance with CMS and CDC recommended practices and related regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Census: 37
Capacity: 38
Deficiencies: 12
Date: Sep 18, 2019
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, safety, and facility maintenance.
Findings
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.
Deficiencies (12)
Failure to ensure resident rooms were free of heavy urine odor affecting residents #33 and #34.
Failure to ensure timely criminal background checks and employee disqualification listings for new hires.
Failure to transcribe and follow physician orders for pacemaker checks, wound care, and medication administration for residents #15, #26.
Failure to thoroughly document and investigate falls for resident #4.
Failure to ensure monthly pharmacy drug regimen review recommendations were completed, reviewed, and acted upon for resident #4.
Failure to implement gradual dose reductions and proper documentation for psychotropic medications for residents #15 and #28.
Medication administration error rate exceeded 5%, including insulin administration errors for residents #15 and #24.
Failure to ensure medications were labeled correctly with expiration dates and removal of expired medications from medication carts and refrigerators.
Failure to ensure dumpster lids closed properly to prevent animal access.
Failure to maintain food service areas and equipment in a clean and sanitary condition, including dishwasher nozzles, refrigerator gaskets, cutting boards, and improper storage of food items.
Failure to implement infection prevention and control practices including improper storage of oxygen equipment, failure to clean glucometers properly, inadequate hand hygiene during wound care and medication administration, improper storage of Foley catheter bags and graduates, and incomplete tuberculosis testing and screening.
Failure to maintain facility equipment and environment in good repair including dusty fans, damaged shower chair, peeling paint, and damaged commode seats.
Report Facts
Medication administration error rate: 6.9
Facility census: 37
Total capacity: 38
Fall assessment scores: 22
Fall assessment scores: 24
Fall assessment scores: 26
Medication doses: 26
Medication doses: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Assistant B | CNA | Noted urine odor source and oxygen tubing storage practices |
| Licensed Practical Nurse A | LPN | Involved in medication administration errors, infection control deficiencies, and interviews regarding practices |
| Director of Nursing | DON | Provided explanations and expectations regarding medication administration, infection control, and facility practices |
| Human Resource Director | Discussed delays in employee background checks | |
| Dietary Manager | DM | Discussed food service deficiencies and dumpster lid issues |
| Dietary Aide A | DA | Commented on food storage practices |
| Certified Medication Technician A | CMT | Discussed catheter care and oxygen tubing storage |
| Certified Medication Technician B | CMT | Mentioned in background check deficiency |
Inspection Report
Annual Inspection
Census: 37
Capacity: 38
Deficiencies: 13
Date: Sep 18, 2019
Visit Reason
The inspection was the annual survey of Armour Oaks Senior Living Community to assess compliance with health and safety regulations and to identify any deficiencies.
Findings
The facility was found to have multiple deficiencies related to resident care, medication management, infection control, environmental safety, and documentation. Several residents were at risk due to inadequate care practices and incomplete medical records.
Deficiencies (13)
F584 Safe Environment: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including issues with odors and cleanliness in resident rooms.
F607 Abuse/Neglect Policies: The facility did not ensure comprehensive policies and procedures for abuse prevention and background checks were followed.
F684 Quality of Care: The facility failed to ensure physician orders were transcribed and followed, and residents received appropriate medication and wound care.
F689 Resident Rights: The facility did not thoroughly document and investigate falls and failed to provide adequate supervision and care to prevent injuries.
F756 Drug Regimen Review: The facility failed to ensure monthly pharmacy drug regimen reviews were completed and recommendations acted upon.
F758 Psychotropic Drugs: The facility failed to ensure psychotropic drugs were administered and monitored according to regulations.
F759 Medication Errors: The facility failed to maintain medication error rates below 5%, with documented errors in insulin administration and blood glucose monitoring.
F760 Insulin Administration: The facility failed to ensure insulin was administered properly and timely according to physician orders.
F761 Labeling of Drugs and Biologics: The facility failed to label medications correctly and maintain proper storage with expiration dates.
F812 Food Procurement and Safety: The facility failed to maintain food safety standards, including cleaning of dishwasher nozzles and refrigerator gaskets.
F814 Garbage and Refuse: The facility failed to ensure dumpster lids closed properly to prevent animal access.
F880 Infection Control: The facility failed to implement effective infection prevention and control measures, including hand hygiene and cleaning protocols.
F921 Environmental Conditions: The facility failed to maintain a safe, functional, sanitary, and comfortable environment, including broken shower chairs and damaged equipment.
Report Facts
Facility census: 37
Total capacity: 38
Deficiencies cited: 12
Inspection Report
Life Safety
Census: 37
Capacity: 38
Deficiencies: 16
Date: Sep 18, 2019
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and life safety code provisions.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to complete a hazard vulnerability analysis, lack of alternate care site listings, incomplete communication backup plans, and failure to conduct required emergency exercises. Life safety deficiencies included penetrations in smoke barriers, combustible storage under stairs, grease buildup in cooking facilities, smoking regulation violations, and improper storage of oxygen cylinders.
Deficiencies (16)
E004: The facility failed to complete an all hazards analysis in its disaster preparedness plan, affecting all residents.
E025: The facility failed to list alternate care sites in the Emergency Preparedness Plan, potentially affecting all residents.
E032: The facility failed to include a backup communication plan beyond landline or mobile phones in its Disaster Manual, affecting all residents and staff.
E039: The facility failed to schedule and conduct a required tabletop exercise annually to test the emergency plan, affecting all residents and staff.
K161: The facility failed to ensure smoke barriers in the Director of Nursing's office prevented smoke passage, affecting two smoke zones.
K300: The facility failed to prevent storage of combustibles under stairs in the dietary dry goods storage room, affecting two smoke zones.
K324: The facility failed to maintain the range hood cleaning system, resulting in heavy grease buildup in the exhaust system.
K741: The facility failed to ensure noncombustible, self-closing ashtrays were used in staff smoking areas, affecting two smoke zones.
K926: The facility failed to provide in-service training on gas equipment safety and proper storage of oxygen cylinders, affecting one smoke zone.
A2002: The facility improperly stored combustibles under stairways, violating fire safety regulations.
A2003: The facility presented a fire hazard in building construction, violating fire safety regulations.
A2010: The facility improperly stored oxygen cylinders, violating fire safety regulations.
A2017: The facility failed to maintain and certify cooking range hood extinguishing systems as required.
A3001: The facility failed to maintain the building in good repair, violating construction and maintenance standards.
A4013: The facility failed to develop and implement policies and procedures to ensure resident health and safety.
A4015: The facility failed to fully inform personnel of policies and duties related to resident care and safety.
Report Facts
Facility census: 37
Licensed capacity: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Plant Operations Manager | Assistant Plant Operations Manager (APOM) | Interviewed regarding hazard analysis and emergency preparedness plan |
| Director of Nursing | Director of Nursing (DON) | Interviewed and observed regarding smoke barrier penetration and smoking area violations |
| Plant Operations Manager | Plant Operations Manager (POM) | Interviewed regarding emergency preparedness communication systems |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen cylinder storage education |
| Day Shift Charge Nurse | Day Shift Charge Nurse | Corrected oxygen tank placement and disposal of refuse |
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 1
Date: Oct 3, 2018
Visit Reason
The inspection was conducted to assess compliance with medication storage and accessibility regulations at Armour Oaks Senior Living Community.
Findings
The facility failed to ensure all medications were safely stored in a secured location behind at least one locked door or cabinet. Observations showed medication carts left unattended and medications accessible outside locked storage.
Deficiencies (1)
19 CSR 30-86.047(41) Medication Storage/Accessibility: The facility failed to keep all medications safely stored behind at least one locked door or cabinet, with medication carts left unattended and accessible to residents.
Report Facts
Resident census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practitioner Nurse (LPN) | Interviewed regarding medication storage and resident behavior | |
| Director of Nursing | Interviewed about staff education on medication storage | |
| LPN Charge Nurse | Responsible for disposal of empty insulin pen and resident education in plan of correction | |
| Administrator | Responsible for monitoring corrective actions and staff education |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 11
Date: Sep 7, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations at Armour Oaks Senior Living Community.
Findings
The facility was found deficient in multiple areas including resident rights, background checks for employees, care plan revisions, medication storage and management, food safety, infection control, and pest control. Several residents were identified as at risk for wandering and falls, with inadequate supervision and care planning.
Deficiencies (11)
F574 Resident rights: The facility failed to ensure residents had access to contact information for the State Ombudsman and resident rights poster was not properly posted.
F606 Background checks: The facility failed to complete criminal background and employee disqualification checks prior to hiring two employees.
F657 Care plans: The facility failed to update or revise care plans for residents with fall interventions and wandering risk.
F689 Accident hazards: The facility failed to provide adequate supervision and assistance devices to prevent accidents for residents at high risk for wandering.
F697 Pain management: The facility failed to document non-pharmacological interventions prior to administering PRN narcotic pain medication for one resident.
F761 Labeling and storage of drugs: The facility failed to ensure expired medications were removed, medication storage was secure, and medication refrigerator temperatures were monitored.
F805 Food safety: The facility failed to ensure food was prepared to meet individual needs and maintain proper food storage and cleanliness standards.
F812 Food procurement and sanitation: The facility failed to maintain clean floors, cutting boards, and food storage areas, and failed to maintain proper food temperatures.
F814 Garbage and refuse: The facility failed to ensure the outdoor dumpster lid was intact and closed to prevent pest access.
F880 Infection control: The facility failed to establish and maintain an infection prevention and control program including proper hand hygiene and glove use.
F925 Pest control: The facility failed to maintain an effective pest control program to prevent gnats and other pests in the kitchen and food areas.
Report Facts
Facility census: 35
Resident sample size: 12
Resident sample size: 27
Resident sample size: 13
Resident sample size: 3
Resident sample size: 4
Resident sample size: 15
Resident sample size: 199
Resident sample size: 23
Inspection Report
Life Safety
Census: 35
Capacity: 38
Deficiencies: 21
Date: Sep 7, 2018
Visit Reason
Life Safety Code Survey conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations.
Findings
The facility was found not in compliance with several Life Safety Code provisions including egress door locking, discharge from exits, sprinkler system maintenance, hazardous area enclosures, fire watch policy, corridor door latching, fire drills, smoking regulations, electrical system maintenance, and emergency preparedness. Multiple deficiencies were identified that potentially affected residents, staff, and visitors.
Deficiencies (21)
K222: The facility failed to ensure a door to the crawlspace between the Skilled Nursing Facility and the Assisted Living facility could be unlocked from the inside, creating a risk of entrapment.
K271: The facility failed to prevent pooling of water at the edge of a ramp exit discharge, potentially affecting residents in multiple smoke zones.
K300: The facility failed to ensure mop heads were air dried and not placed in the laundry dryer, posing a fire risk.
K321: Doors to hazardous areas such as Medical Records and Soiled Linen rooms were propped open, failing to maintain fire barriers and self-closing doors.
K353: The facility failed to ensure sprinkler heads in the basement Activities Storage room were not obstructed, risking sprinkler system effectiveness.
K354: The sprinkler system was out of service and the facility failed to provide a fire watch plan and notify authorities during the impairment.
K363: Corridor doors to resident rooms and charting areas were obstructed or failed to latch properly, compromising smoke compartmentation.
K500: The facility failed to provide documentation of damper inspections and maintenance to demonstrate compliance with smoke control requirements.
K711: The facility failed to include a directive for staff to call the local fire department in its fire safety plan and failed to train staff accordingly.
K712: Fire drills were not conducted at varied times and dates as required, and documentation showed drills were not consistently performed.
K741: The facility failed to prevent disposal of cigarette butts in non-designated areas and failed to provide self-closing ashtray containers in designated smoking areas.
K914: The facility failed to maintain and test hospital-grade electrical receptacles in resident rooms and failed to provide documentation of inspections.
K918: The facility failed to maintain and test emergency power systems and circuit breakers, and lacked documentation of required inspections and maintenance.
E001: The facility failed to include all four components of emergency preparedness in its disaster plan, affecting all residents and staff.
E009: The facility failed to maintain correct phone numbers for emergency management agencies and failed to include a process for cooperation and collaboration.
E015: The facility failed to develop and implement emergency preparedness policies and procedures addressing subsistence needs for staff and patients.
E022: The facility failed to develop and implement policies and procedures for sheltering in place and communication during system failures.
E024: The facility failed to include contact information for all current employees in the emergency staff contact page, affecting communication during emergencies.
E025: The facility failed to develop and implement emergency preparedness policies addressing coordination with other facilities and transportation entities.
E026: The facility failed to develop and implement emergency preparedness policies related to 1135 Waiver use during major disasters or emergencies.
E036: The facility failed to develop and implement training and testing policies for emergency preparedness, affecting all staff and residents.
Report Facts
Facility census: 35
Total licensed capacity: 38
Number of smoke zones: 5
Number of deficiencies cited: 20
Inspection Report
Life Safety
Census: 31
Deficiencies: 7
Date: Jul 16, 2018
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with fire safety regulations including range hood extinguishing systems, floor separation doors, smoke section partitions, sprinkler systems, smoking policies, and room cleanliness.
Findings
The facility failed to maintain required fire safety systems including the range hood extinguishing system, floor separation doors, smoke partitions, and sprinkler system. Smoking was not properly controlled in designated areas, and rooms were not consistently neat and orderly.
Deficiencies (7)
19 CSR 30-86.022(4)(B)(1)(2) Range Hood Extinguishing Systems. The facility failed to maintain the range hood extinguishing system as required, obstructing access to the pull station.
19 CSR 30-86.022(10)(E) Floor Separation/Doors. The facility failed to maintain fire/smoke separation doors on the first and second floors that do not close and latch properly.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to maintain smoke separation doors that fully close, with broken closing mechanisms and wedged doors.
19 CSR 30-86.022(11)(C) Sprinkler System Required by 12/31/12. The facility failed to have an approved sprinkler system installed as required.
19 CSR 30-86.022(11)(G) Sprinkler System Out of Service More Than 4hr. The facility failed to ensure proper fire watch procedures when the sprinkler system was out of service.
19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised. The facility failed to ensure smoking was permitted only in designated areas and supervised.
19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily. The facility failed to ensure rooms were neat, orderly, and cleaned daily, with excessive combustible materials and clutter.
Report Facts
Facility census: 31
Deficiencies cited: 7
Report
Jan 16, 2024
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