Armour Oaks Senior Living Community

Inspectors wroteBased on interview and record review, the facility failed to contact Emergency Medical Services (EMS), to initiate and provide continuous Cardiopulmonary Resuscitation (CPR) timely per facility policy for one sampled resident (Resident #1) out of three sampled residents, who was a full code status. The facility census was 31 residents. The Administrator and Director of Nursing (DON) were notified on [DATE] at 2:45 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Administrator and DON became aware of the violation of the facility's CPR policy. The facility in-serviced the staff on the CPR policy and procedures, medical emergencies and ensured code status updates for all residents. The IJ was corrected on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication refrigerator had a thermometer and the temperature was checked daily, failed to ensure the freezer compartment of the medication refrigerator was not frozen solid, failed to ensure there were no loose pills in the medication cart, failed to ensure medications that were opened had the date they were opened written on them, failed to ensure there were no other items kept in the medication cart in with the resident's prescribed medications and failed to ensure there were not cleaning agents in the medication cart in with the resident's prescribed medications. The facility census was 36 residents. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate measures were taken to provide safe and sanitary conditions for food storage and preparation by not maintain cleanliness of the kitchen and kitchen equipment; not labeling and dating opened food; not wearing appropriate hair coverings; not cleaning utensils; not documenting food temperatures during preparation; not documenting refrigeration temperatures. The facility census was 36 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP - precautions taken by a facility for the prevention of transmission of multidrug-resistant organisms) for three sampled residents (Resident #24, Resident #7, and Resident #8); failed to ensure accurate documentation of a resident's tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) skin test for five sampled residents (Residents #3, #4, #6, #9, and #18) out of 12 sampled residents and failed to ensure hand hygiene was completed during medication pass. The facility census was 36 residents. Review of the facility's policy, Enhanced Barrier Precautions, dated 2022 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate measures were taken to provide safe conditions for food storage by not maintaining documentation of walk-in freezer temperatures. The facility census was 36 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rights were being honored by not treating one resident (Resident #9) out of 12 sampled residents, with dignity while standing up next to the resident and being assisted with eating during scheduled mealtimes. The facility census was 36 residents. A policy regarding feeding assistance was requested and not received.1. Review of the resident's face sheet, undated, showed:-The resident was admitted [DATE].-The resident was diagnosed with aphasia (a condition affecting speech caused by a stroke). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the correct code status (a form or statement that indicated preferences to receive life sustaining measures such as cardio-pulmonary resuscitation (CPR)) was documented in the Electronic Health Record (EHR) for one resident (Resident #4) out of 12 sampled residents. The facility census was 36 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders when weights were not monitored, documented and reported for one resident (Resident #9) diagnosed with Congestive Heart Failure (CHF- condition where the heart muscle did not pump blood effectively enough to meet the body's needs) out of 12 sampled residents. The facility census was 36 residents. Review of the facility's Medication Administration policy, dated 10/2022, showed to obtain and record vitals (heart rate, pulse, blood pressure and weights) per physician orders.1. Review of the Resident #9's face sheet, undated, showed:-The resident was admitted to the facility on [DATE].-The resident had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's oxygen equipment was kept in a sanitary manner when not in used for two sampled residents, (Resident #36 and Resident #37) out of 12 sampled residents. The facility census was 36 residents. Review of the facility's policy, Oxygen Concentrator, dated 2022 showed:-Staff was responsible for the use and care of oxygen concentrators.-Keep delivery devices covered in a plastic bag when not in use.-Change oxygen tubing and mask weekly and as needed if it becomes soiled or contaminated.-Change nebulizer tubing devices every 72 hours. 1. Review of Resident #36's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the door between the kitchenette and the dining room in good repair; failed to prevent the accumulation of debris inside the climate control units of resident rooms [ROOM NUMBERS]; failed to ensure the cover of the cleanout was secured firmly to the floor. This practice potentially affected at least 25 residents who used the dining room and 4 residents who resided in resident rooms [ROOM NUMBERS]. The facility census was 36 residents.1. Observation on 8/18/25 at 10:32 A.M., showed the half door, which separated the dining room from the serving kitchenette dragged on the floor when it was opened and closed. During an interview on 8/18/25 at 10:33 A.M., Maintenance Person A said the door dragged on the floor due to a loose hinge. During an interview on 8/20/25 at 12:44 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of controlled substances for three sampled residents (Resident #1, #2, #3) when Registered Nurse (RN) A repeatedly signed out duplicate doses of narcotics out of five sampled residents. The facility census was 100 residents. On 5/7/25 the Administrator was notified of the situation and RN A was suspended immediately pending investigation. Upon completion of the investigation, RN A was terminated for violating facility policy on 5/1/25, 5/4/25 and 5/6/25. Training was completed immediately for 100% of all nurses and Certified Medication Technicians (CMT)s on abuse and neglect, medication administration and controlled substances prior to being allowed to work and/or pass medications. The deficiency was corrected on 5/7/25. Review of the facility Abuse, Neglect, and Exploitation policy dated 2022 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that hot water temperatures from faucets throughout the facility, were consistently between 105 ºF (degrees Fahrenheit) and 120 ºF. Resident rooms [ROOM NUMBER]) on the South east side of the facility, had water temperatures between 94 ºF and 99 ºF. Resident rooms 14, 21, 22, and 12 on the north side of the facility had temperatures that were 120.2- 121.4 ºF; and Resident rooms [ROOM NUMBERS] had water temperatures between 76.1 ºF and 92.3 ºF .The facility also failed to ensure that staff who are checking temperatures allowed to flow for at least 2 minutes before measuring the water temperatures. This practice potentially affected all residents. The facility census was 35 residents. Review of the facility's policy entitled Safe water Temperatures and dated 3/23, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; failed to safeguard against mold possibly getting into food and/or beverages; failed to change the deep fryer oil in a timely manner; failed to consistently document hot food temperatures at the steam table to ensure they were suitably cooked to lessen the chance of bacterial contamination; failed to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and failed to store foodstuffs within acceptable temperature parameters, in accordance with professional standards for food service safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 34 residents with a licensed capacity for 38 residents at the time of the survey. 1. Observation on 1/8/24 between 9:41 A.M. and 10:43 A.M. during the Life Safety Code (LSC) kitchen inspection showed a three-sink area, a chemical dish-washing machine, a handwashing sink, and an ice machine. Observation on 1/11/23 between 12:47 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for three sampled residents (Residents #19, #31 and #3) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's MDS 3.0 completion policy dated 2022 showed the facility would conduct an accurate assessment of the resident. 1. Review of Resident #19's care plan dated 3/1/23 showed: -The resident had a regular diet with mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow. Foods are finely chopped, blended, or ground to make them smaller, softer, and easier to chew) and regular, thin liquids. -The resident admitted to hospice services (end of life care) on 5/19/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility reported an allegation of abuse immediately to the Administration when on 1/1/24 Certified Medication Technician (CMT) B attempted to get Resident #30's vital signs (temperature, pulse and respirations) which resulted in the resident becoming agitated, yelling and remaining upset after the alleged incident out of 12 sampled residents. The facility started their investigation on 1/8/24 seven days after the alleged incident. The facility census was 34 residents. Review of the facility's Abuse, Neglect and Exploitation policy dated 10/2022 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification of transfer from the facility for two sampled residents (Residents #17, and #32) out of 12 sampled residents. The facility census was 34 residents. The facility did not have a policy for Ombudsman notification. 1. Review of Resident #17's admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Acute (severe and sudden onset) respiratory failure (a condition where there is not enough oxygen in body tissues) with hypoxia (insufficient oxygen in the blood). -Pneumonia (an infection that affects one or both lungs). [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a resident's discharge assessment for one supplemental resident (Resident #28) out of four residents who triggered for assessment concerns. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #28's discharge assessment dated [DATE] showed it was not submitted to Centers for Medicare & Medicaid Services (CMS) and was marked do not submit to CMS on 9/8/23. Review of the Resident Assessment Instrument (RAI) Manual dated October 2023 showed the following on page 1 of chapter 5: -Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS a federally mandated assess tool completed by facility staff for care planning) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan that included one high risk medication for one sampled resident (Resident #31) out of five residents sampled for medication review. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #31's care plan dated 12/28/23 showed no care plan for the use of anticoagulant medication. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed the resident was on an anticoagulant (medication used to slow down the blood clotting process) medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered safely and were not left at bedside for one sampled resident (Resident #25) and to prime a insulin pen prior to administration for one sampled (Resident #23) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's Resident Self-Administration of Medication Policy dated November 2017 showed: -A Resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. -All Nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to put adequate supervision measures in place to prevent a newly admitted resident, who was assessed to be an elopement risk and showed signs of confusion and exit seeking behaviors, from leaving the facility unannounced for one sampled resident (Resident #335) and to complete an Annual or quarterly Safe Smoking Assessment to assess the resident's ability to safely smoke electronic cigarette with or without supervision for one sampled resident (Resident #20) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's Elopement and Wandering Resident policy/procedure, dated 2022, showed: -Residents would be assessed for their risk of elopement and unsafe wandering upon admission and throughout their stay. [...]

Inspectors wroteBased on interview and record review, the facility failed to respond to the pharmacist's recommendations for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents. Review of the facility's Medication Regimen Review (MRR) policy dated October 2022 showed: -The pharmacist shall document the findings for each MRR. -The pharmacist shall communicate any irregularities verbally to the physician, Director of Nursing (DON) and/or staff of any urgent needs. -The pharmacist shall communicate any irregularities in written communication to the attending physician, the facility's medical director and the DON. -Facility staff shall act upon all recommendations according to procedures. 1. Review of Resident #31's entry tracking form dated 12/22/23 showed the resident newly admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were ordered with adequate monitoring for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #31's entry tracking form dated 12/22/23 showed the resident newly admitted to the facility on [DATE]. Review of the resident's care plan dated 12/28/23 showed: -The resident had a diagnosis of high blood pressure. -There was no care plan for anticoagulant (medication used to slow down the blood clotting process) medication. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/29/23 showed: -Some of the resident's diagnoses included heart disease and high blood pressure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure target behaviors and side effects were being monitored for psychotropic medications (any medications that affect brain activities associated with mental processes and behavior) for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 34 residents. There were no policies for this example. 1. Review of Resident #31's care plan dated 12/28/23 showed the resident used an antidepressant (medications used to treat depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and an antianxiety (used to treat anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) medication with instructions to monitor and document side effects and effectiveness every shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) on duty eight hours a day, seven days a week. This deficient practice had the potential to negativly affect all residents residing at the facility. The facility's census was 37 residents. Record review of the facility's undated Registered Nurse Staffing Policy, showed: -The facility interpreted state and federal guidelines to say the facility must use the services of a RN for at least eight consecutive hours a day, seven days a week. -The Director of Nursing (DON) or designated staffing coordinator scheduled at least one eight-hour shift each day on the nursing schedule. -The eight hour shift will be suffice by the RN each day the DON is on site for at least eight consecutive hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage room, and walk-in refrigerator and walk-in freezer floors clean; to retain operable thermometers in all freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; to follow correct hair hygiene practices; and to separate damaged foodstuffs. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 37 residents with a licensed capacity for 38 residents. 1. Observations during the initial kitchen inspection on 7/13/22 between 8:52 A.M. and 12:15 P.M. showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The facility also failed to ensure two sampled residents (Resident #14 and #26) were tested/screened for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function). The facility census was 37 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft by failing to document personal belongings upon admission and to follow-up timely as part of the grievance process when clothes were reported missing for three sampled residents (Resident #14, Resident #25, and Resident #33) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated abuse, neglect and exploitation showed: -The facility must take appropriate steps to prevent misappropriation of resident property. -Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative (if applicable) with a written summary of the baseline care plan for three sampled residents (Residents #26, #14 and #22) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated Base Line Care Plans policy showed: -Every resident had an interdisciplinary care plan initiated within 24 hours of admission. -The care plan identified priority problems and needs to be addressed by the interdisciplinary team (IDT). -The resident and/or the family member was involved in the care planning. -The facility developed and implemented a base line care plan for each resident that included effective and person-centered care of the resident that met professional standards of quality of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide daily oral care to include brushing of teeth to one sampled resident (Resident #20); and to provide fresh water daily to two sampled residents (Resident #20 and #33) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated policy titled Nutrition/Hydration Status Maintenance showed based on a resident's comprehensive assessment, the facility will ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health. Record review of the facility's undated policy titled Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) showed: -It is the policy of the facility to sustain an environment that humanizes and individualizes each resident's quality of life. [...]

Inspectors wrote2. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Seizures (a sudden uncontrolled electrical disturbance in the brain). -Anemia (a condition in which the blood doesn't have enough healthy red blood cells). -Urine retention (a condition in which your bladder doesn't empty completely each time you urinate). -Edema (swelling caused by excess fluid trapped in your body's tissues). -Open angle glaucoma (a condition that causes nerve damage to nerve at the back of the eye). Record review of the resident's care plan dated 11/27/18 showed: -The resident was able to complete bed mobility, transfers and ambulation independently. -The resident was at risk for falls due to unsteady gait at times and shuffling gait dated 5/3/18. -Staff was to complete the fall risk assessment quarterly and PRN (as needed) dated 5/3/18. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' prescription medications that had been opened had the date the medication was opened written on the container; to ensure medication containers were clean, and to ensure residents personal belongings were not mixed in with medications. The facility census was 37 residents. Record review of the facility's policy, Medication Storage in the Facility, dated 10/4/18 showed: -Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were to be immediately removed from stock, disposed of according to procedures for medication disposal. -Medication storage areas were kept clean, well-lit, and free of clutter. -Medication storage conditions were monitored on a monthly basis and corrective action was taken if problems were identified. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free of misappropriation for one sampled resident (Resident #25) out of 12 sampled residents when the resident's debit card was used for $303.69 in unauthorized purchases. The facility's census was 37 residents. Record review of the facility's undated abuse, neglect and exploitation showed: -The facility took appropriate steps to prevent misappropriation of resident property. -Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the State and the local Police within 24 hours, when a resident reported fraudulently charges on his/her credit card. This deficient practice negatively affected one sampled resident (Resident #25) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated abuse, neglect and exploitation showed: -Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful use, either temporary or permanent, of a resident's belongings, prescriptions or money without the resident's consent. -Reporting was defined as immediately reporting alleged violations involving misappropriation of resident property to the Administrator and/or Director of Nursing (DON) or other officials in accordance with state law. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility policy to have a nebulizer (a device used to administer medication to people in the form of a mist inhaled into the lungs) mask stored in a bag when not in use for one sampled resident (Resident #14) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's undated Oxygen and Nebulizer guidelines showed all nebulizer tubing must be kept in a bag when not in use. 1. Record review of Resident #14's record summary showed: -The resident moved into the facility on 5/17/22. -Some of the resident's diagnoses included: --Chronic obstructive pulmonary disease (COPD). --Hypoxemia (low oxygen levels in the blood). [...]