Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Armour Oaks Senior Living Community during CMS and state inspections, most recent first.
Failure to provide timely CPR and EMS activation for a resident with conflicting code status documentation. A resident admitted for respite care with Hospice services was documented as Full Code in the chart, while other records referenced DNR status. When the resident was found unresponsive, staff were confused about the code status, CPR was delayed, and there was disagreement among the DON and LPNs about whether a signed DNR was present before life-saving measures were started.
Medication storage and labeling were not maintained properly in the cart and medication refrigerator. Observations found loose pills, unlabeled medication cups, opened bottles without open dates, bleach wipes and a walkie talkie stored with residents’ meds, and a medication refrigerator without a thermometer, with missed temperature checks and a freezer frozen solid. An LPN and the DON acknowledged the improper storage conditions and that daily temperature monitoring was expected.
Surveyors found multiple food service sanitation and documentation failures, including dirty kitchen and cooler areas, grease buildup, unclean utensils, and improperly stored items. Opened foods were observed without labels or dates, some expired or stored incorrectly, and dented cans were on the ready-to-serve rack. Food and cooler temp logs were incomplete or missing, several thermometers were not usable or not present, and staff were observed without required hair restraints.
Infection Prevention and Control Failures: Staff did not follow EBP for residents with wounds and indwelling devices, with observations showing care provided without PPE, no EBP signage, and no isolation carts at the rooms. The facility also had incomplete TB skin test documentation for several residents, including missing read dates and one admission test without a second step, and hand hygiene was not performed during medication pass as required.
Facility staff failed to maintain walk-in freezer temp logs and did not ensure safe food storage monitoring. The freezer thermometer was broken, the internal temp read 22 F, and melting ice cream was observed. Logs for the month were incomplete or missing, and staff gave inconsistent accounts of who was responsible for checking and documenting equipment temps.
Failure to preserve dignity during feeding assistance: A resident with aphasia, moderate cognitive impairment, and a need for eating assistance was observed being fed by an aide who stood next to and over the resident during lunch, with another aide also standing while assisting another resident. A later observation showed an aide standing over a resident in a Broda chair while wiping the resident's face during breakfast. Staff interviews confirmed aides were expected to sit with residents during meals, communicate with them, and avoid towering over them, but some aides were observed standing while providing feeding assistance.
Incorrect Code Status Documented in EHR: A cognitively intact resident was listed as DNR in the POS and care plan, but no DNR form was found in the chart and the EHR contained the wrong code status. Staff interviews showed conflicting information about where advance directives were kept, and the MDS coordinator stated another resident’s code status had been entered into the file by mistake.
Failure to Complete and Document Ordered Daily Weights: A resident with CHF and edema had a physician order for daily weights and Torsemide, but the TAR showed multiple missed weights and only one documented weight during the ordered monitoring period. Staff interviews confirmed that CNAs or nurses were responsible for obtaining and documenting weights, yet the ordered daily monitoring was not consistently completed or recorded.
Oxygen equipment was not kept in a sanitary manner for two residents. One resident with COPD had a CPAP machine and mask found in a drawer, on a solid pad, on the same dirty pad, and later inside a pillowcase instead of being stored in a bag. Another resident with COPD and chronic respiratory failure had a nebulizer mask left in a nightstand drawer not in a bag. Staff interviews confirmed that oxygen equipment should be stored in a bag when not in use and that nurses were responsible for correct storage.
Door, Climate Control Units, and Cleanout Cover Not Maintained in Good Repair: The dining room half door dragged on the floor when opened and closed because of a loose hinge, and staff reportedly leaned on it when open. Debris, including a decoration, was observed inside climate control units in resident rooms, with maintenance stating the grates allowed items to accumulate. A loose cleanout cover outside the laundry also moved when stepped on, and maintenance was unaware it was not tightened.
A registered nurse repeatedly signed out duplicate doses of narcotics for three cognitively impaired residents, including those with heart failure, chronic respiratory failure, dementia, and chronic pain. The nurse failed to properly document or account for these additional doses, and staff did not consistently follow facility policy for controlled substance reconciliation, leading to medication discrepancies that were discovered during an internal investigation.
The facility did not consistently maintain hot water temperatures between 105°F and 120°F at resident faucets, with some rooms experiencing water that was too cold and others exceeding the safe maximum. Staff did not follow proper procedures for measuring water temperatures, and leadership was unaware of the extent of the issue until a resident incident occurred. These failures potentially affected all residents.
Failure to Provide Timely CPR for a Full Code Resident
Penalty
Summary
The facility failed to contact EMS and failed to initiate and maintain CPR in a timely manner for one resident who was documented as Full Code. The resident was admitted for respite care with Hospice services in place, had a blank advance directive section on admission, and the record also contained conflicting code status documentation, including a Hospice record showing no DNR order and a care plan indicating DNR. The resident’s progress notes described a decline with fever, watery stool, draining feeding from the mouth, low blood pressure, a pulse of 35, and later unresponsiveness. On the morning of the event, staff documented that the resident was found unresponsive at 8:31 A.M. The note states that family could not be reached, the DON was informed, 911 was called, and staff started CPR on the floor until paramedics arrived and took over. The resident was pronounced dead at 9:01 A.M. The record also showed an Outside the Hospital Do-Not-Resuscitate Order signed by the physician, but staff interviews described confusion about whether the resident was Full Code or DNR at the time of the emergency. During interviews, the DON stated the resident remained Full Code unless a DNR document from Hospice was present and said life-saving measures were to be done until EMS were onsite if no DNR document existed. LPN A stated the resident’s computer profile showed DNR and that the DON told him/her to start CPR, but he/she delayed action and said there was no official copy of the DNR in the facility until after the resident had passed. LPN B stated that when he/she checked the chart, the resident was Full Code, there was no DNR form located, and CPR should have been started immediately. The Medical Director also stated staff were required to do CPR unless the signed DNR document was present and that CPR should have been started in this situation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional principles. During observation of the Certified Medication Technician medication cart, there was a facility walkie talkie and a container of bleach wipes stored with residents’ prescribed medications, an opened bottle of Enulose without the date opened, four white capsules in an unlabeled medication cup, and loose pills in the cart drawer. The CMT stated there should not have been loose pills, bleach wipes, or a walkie talkie in the cart, and that opened prescribed medications should have been dated. During observation of the nurses’ medication cart, medication room, and medication refrigerator, there was no thermometer in the medication refrigerator, no temperature recorded for two consecutive days on the temperature log, and the freezer compartment was frozen into one solid block of ice. The refrigerator also contained four boxes of TB vials and one Glargine insulin pen. The medication cart contained a loose Ondansetron tablet, an opened bottle of Guaifenesin without an open date, and a container of bleach wipes stored with residents’ medications. Facility staff interviews confirmed the conditions observed. The LPN stated there should not have been loose pills, other objects, or bleach wipes in the medication cart and did not know how the refrigerator temperature would be checked without a thermometer. The DON stated the night nurse was responsible for daily temperature checks, the temperature should have been recorded daily, the freezer should not have been a block of ice, and the DON was ultimately responsible for the medication carts, medication refrigerator, and medication room.
Kitchen sanitation, labeling, temperature monitoring, and hair restraint failures
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation conditions in the kitchen and related food service areas. During observation, surveyors found dirty kitchen floors, sticky areas in the kitchen, storage area, and walk-in coolers, grease buildup on stove hoods, and grease dripping onto the stove surface. Coffee filters were stored in a box with a dried brown substance on a food cart, salad dressing jars in the walk-in cooler were caked with dried-on residue, and utensils stored under the wall-mounted knife holder included three knives with dried food particles stuck to them. The facility also had a broken thermometer on the outside of the walk-in cooler, and the hanging thermometer inside could not be read without moving large jars of salad dressing. The facility did not consistently label or date opened food items. Surveyors observed an opened bottle of pancake syrup that was not labeled, an opened and undated jar of pickles that was also expired by the manufacturer date, an opened bottle of grape jelly stored unrefrigerated despite the label stating it should be refrigerated after opening, an opened package of sliced cheese with no date, and an opened container of sour cream with no opening date. In the kitchenette refrigerator on the unit, opened sliced cheese, an opened gallon of milk, and an opened bottle of grape jelly were found without labels or open dates. Dented cans of pineapple and mandarin oranges were also observed on the ready-to-serve storage rack. The facility did not document food temperatures and refrigeration temperatures as required by its own policies. Review of the logs showed multiple missing meal temperature entries in July and August, and no additional August food temperature logs were provided. Cooler temperature logs were also incomplete, with missing entries in July and no August equipment temperature logs provided. During observation, the reach-in cooler had a blank August temperature log, the walk-in cooler had no temperature log, and the stand-up freezer used for bread had no temperature log. Staff interviews stated that food and equipment temperatures were checked and recorded, but the records reviewed and the observations did not reflect consistent documentation. Staff were also observed not wearing required hair restraints, including a dishwasher with a beard net tucked below the chin and the Dining Services Director in food prep and cooking areas without a hair net or beard net.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for three residents who had conditions requiring those precautions. Resident #24 was admitted with a Stage 2 pressure ulcer on the buttock and had orders for EBP related to dressing care and wound treatment. During observation, staff entered the room and provided care without donning PPE, there was no sign on the door indicating EBP, and there was no isolation cart at the room or in the hallway. The resident stated staff did not wear PPE when providing care. Resident #7 had diagnoses including protein calorie malnutrition, adult failure to thrive, and dysphagia, and had a feeding tube. The resident had an order for EBP related to the PEG tube with gown and gloves during cares. During observation, staff entered the room and provided care without PPE, there was no sign on the door for EBP, and there was no isolation cart nearby. Resident #8 had obstructive uropathy, urinary retention, a history of UTIs, and an artificial opening of the urinary tract with a suprapubic catheter. The resident had an order for EBP related to the suprapubic catheter, but staff completed cares without PPE, there was no sign on the door, and there was no isolation cart in place. The resident stated staff had emptied the Foley and had not worn a gown, only gloves. The facility also failed to ensure accurate TB skin test documentation for five residents. Review of records showed annual or admission TB skin tests documented as 0 mm induration, but the read dates were not recorded for Residents #3, #6, #9, and #18. Resident #4 had an admission TB skin test documented as 0 mm induration with no read date, and the resident did not have a second-step TB skin test. The DON stated TB skin test results should be read 48 to 72 hours after administration and the read date should be documented, and that all new admissions should have a two-step skin test. In addition, during medication pass observation, a CMT did not cleanse hands before administering medication to one resident and did not cleanse hands after administering medication to two residents.
Missing Freezer Temperature Logs and Improper Food Storage Monitoring
Penalty
Summary
The facility failed to maintain documentation of walk-in freezer temperatures and failed to ensure safe food storage conditions were being monitored. Review of the facility’s temperature monitoring policy showed that freezer temperatures were to be checked and logged at least twice per day, with frozen storage maintained at or below -4 F and corrective action taken if temperatures rose above 10 F. However, the July 2025 freezer temperature log was missing temperatures for the entire month, with a squiggly line drawn down the column, and no walk-in freezer temperature logs were provided for August 2025. During observation on 8/18/25 at 10:58 A.M., the walk-in freezer had a broken thermometer outside the unit, the thermometer inside the freezer read 22 F, and a large container of chocolate ice cream was melting. The clipboard used for documenting daily temperatures was dated July 2025 and had multiple blank dates. Staff interviews showed differing understanding of freezer temperature expectations and documentation responsibilities, and one staff member stated the freezer was noticed not working and maintenance had been told about it the prior month. The Dining Services Director and Administrator stated that kitchen staff were responsible for checking and documenting equipment temperatures and that they expected issues with equipment to be reported.
Failure to Preserve Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure resident rights were honored by not treating one resident with dignity during assisted mealtimes. The resident had aphasia related to a stroke, moderate cognitive impairment, and needed supervision and touching assistance while eating, with the care plan stating the resident required assistance with eating and had a swallowing problem related to aphasia. During observation at lunch, the resident was seated at a round table with other residents while an aide stood next to the resident and between the resident and another resident while feeding the resident. Another aide was also observed standing next to another resident while providing feeding assistance. The resident ate 25-50% of the lunch meal. Additional observations showed staff assisting residents with meals while standing over them, including an aide standing over a resident in a Broda chair while wiping the resident's face during breakfast. In interviews, a CNA and a CMT stated they would sit down to feed residents and noted they had seen other aides standing while helping residents eat. An LPN stated aides were expected to sit down and have conversations during mealtimes, and the DON stated aides were expected to communicate with residents while feeding them and to sit next to residents rather than tower over them. The facility did not provide a requested policy regarding feeding assistance.
Incorrect Code Status Documented in EHR
Penalty
Summary
The facility failed to ensure the correct code status was documented in the EHR for one cognitively intact resident who was listed as DNR in the Physician Order Summary and care plan. Review of the resident’s record showed there was no DNR form located in the file, even though the resident’s care plan identified the resident as DNR and staff stated the code status should be available in the chart and EHR. During interviews, staff gave conflicting information about where the resident’s advance directive and code status were kept and how they were documented. The DON stated there should be a DNR book at the nurse’s station and that a paper copy should be in the resident’s chart and scanned into the EHR, while the MDS Coordinator later stated the EHR showed the resident as full code because another resident’s code status had been entered into the file by mistake. The DON also stated the resident’s code status should be documented as an order in the EHR and correctly assigned to the resident.
Failure to Complete and Document Ordered Daily Weights
Penalty
Summary
The facility failed to follow physician orders for daily weights for a resident diagnosed with CHF and edema. The resident’s August 2025 physician orders included Torsemide 40 mg and daily weights for 14 days starting 8/17/25, with notification to the doctor if there was a weight gain of more than three pounds in 24 hours. Review of the TAR showed the resident was not weighed on August 17, 18, 19, or 20, was weighed on August 21 at 136.8 pounds, and was not weighed on August 22. The MAR showed the resident received Torsemide as ordered. During interviews, CNA A, CMT A, LPN A, and the DON stated that aides or nurses completed weights, the weights were written down or entered into the EHR, and daily weights were expected for residents with such orders. The LPN stated that weight changes were reported to the physician, and the DON stated that if there was a change in weight, the charge nurse notified the physician. No additional weight documentation was provided.
Oxygen Equipment Not Stored Sanitarily
Penalty
Summary
The facility failed to ensure that oxygen-related equipment was kept in a sanitary manner when not in use for two residents. The facility policy for Oxygen Concentrator stated that staff were responsible for the use and care of oxygen concentrators, delivery devices were to be kept covered in a plastic bag when not in use, and oxygen tubing and masks were to be changed weekly and as needed if soiled or contaminated. Resident #36 had a diagnosis of COPD and was cognitively intact. The resident’s record showed an order to check and change CPAP tubing weekly. Observations showed the resident’s CPAP machine and mask sitting in the resident’s drawer not in a bag, later the CPAP mask sitting on a visible solid pad, then on the same dirty pad, and later inside the resident’s pillowcase. The resident stated staff put the CPAP in the drawer. Resident #37 had diagnoses of COPD and chronic respiratory failure and had an order for ipratropium-albuterol solution every six hours for cough related to COPD. Observations showed the resident’s nebulizer mask sitting in the drawer of the nightstand not in a bag on two occasions. During interviews, a CMT and an LPN stated oxygen equipment when not in use should be stored in a bag, that they had received education from the DON about oxygen equipment storage, and that nurses were responsible for ensuring the equipment was stored correctly. The DON stated that when not in use oxygen equipment should be stored in a bag and dated when it had been changed out.
Door, Climate Control Units, and Cleanout Cover Not Maintained in Good Repair
Penalty
Summary
The facility failed to maintain the door between the kitchenette and the dining room in good repair. During observation, the half door that separated the dining room from the serving kitchenette dragged on the floor when opened and closed. Maintenance Person A stated the door dragged because of a loose hinge, and the Assistant Plant Operations Director later stated staff lean on the door when it is open, which caused it to drag. The facility also failed to prevent debris from accumulating inside climate control units in resident rooms, including room [ROOM NUMBER] and room 21. Observations showed debris, including a decoration, inside one climate control unit and a buildup of debris inside another. Maintenance Person A stated the slats of the grate covering the climate control units were too wide, allowing more items to accumulate, and said he/she was unaware of the items that had accumulated. In addition, the facility failed to ensure the cover of the cleanout outside the laundry in the basement smoke zone was secured firmly to the floor; when stepped on, the cover moved, and Maintenance Person A stated he/she did not know the cleanout cover was loose and not tightened.
Failure to Prevent Misappropriation of Controlled Substances by RN
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for three residents when a registered nurse (RN) repeatedly signed out duplicate doses of narcotics. The RN signed out additional doses of hydrocodone and clonazepam for multiple residents, beyond what was ordered and documented in the medication administration records (MAR). These additional doses were not properly recorded or accounted for, and there was no documentation in the residents' progress notes regarding the administration or disposition of these extra medications. The affected residents had significant medical conditions, including hypertensive heart disease with heart failure, chronic respiratory failure, age-related cognitive deficits, pain related to prosthetic joint fractures, dementia, and chronic pain. All three residents were noted to have some level of cognitive impairment, which would have limited their ability to recognize or report discrepancies in their medication administration. The discrepancies were identified when staff noticed mismatches between the number of pills in the medication bubble packs and the controlled substance verification sheets. Interviews with staff revealed that the process for counting and reconciling controlled substances was not consistently followed according to facility policy. One nurse would count the pills while the other confirmed the number on the reconciliation sheet, rather than both visually verifying the count together. The RN involved did not provide adequate documentation for the additional doses and was unable to recall specific details about the administration of the medications. The issue was discovered after a medication error was reported, leading to an internal investigation that confirmed repeated medication errors and inaccurate medication counts by the RN.
Failure to Maintain Consistent and Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure that hot water temperatures from faucets throughout the building were consistently maintained between 105°F and 120°F, as required by both facility policy and state regulations. Observations and measurements revealed that water temperatures in various resident rooms ranged from as low as 76.1°F to as high as 121.4°F. Some rooms on the southeast side had water temperatures between 94°F and 99°F, while rooms on the north side had temperatures exceeding the maximum limit, reaching up to 121.4°F. Other rooms had water temperatures below the minimum requirement, with several readings under 105°F. These inconsistencies were found after allowing the faucets to run for two minutes, as per regulatory guidance. Interviews with facility staff indicated a lack of awareness and understanding regarding the proper procedures for monitoring and measuring water temperatures. The Maintenance Assistant described the water delivery system, which includes a hot water heater, a holding tank, and a mixing valve, but could not explain the cause of the temperature fluctuations. The Maintenance Person admitted to not following the correct method for measuring water temperatures, typically allowing water to flow for only one minute instead of the required two minutes. Additionally, the Administrator was unaware of the extent of the temperature variations until an incident involving a resident in the shower was reported. Review of facility policies confirmed that staff are required to monitor water temperatures, report abnormal findings, and maintain documentation. However, the staff interviews and record reviews demonstrated that these procedures were not consistently followed. The facility had not previously contacted a plumber to address the inconsistent water temperatures, and leadership was only considering this action after the issue was identified. The failure to maintain appropriate water temperatures and to follow established monitoring protocols potentially affected all residents in the facility.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 795 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hope Care Center | 0.4 mi | ★★★★★ | 14 | 0 |
| Rehab Of Kansas City South | 0.8 mi | ★★★★★ | 2 | 0 |
| Highland Rehabilitation & Health Care Center | 1.8 mi | ★★★★★ | 4 | 0 |
| Claridge Court | 1.9 mi | ★★★★★ | 10 | 0 |
| The Village At Mission | 2.3 mi | ★★★★★ | 7 | 1 |
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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.