Armour Oaks Senior Living: CPR Failure Kills Resident - MO
The resident at Armour Oaks Senior Living Community was on hospice respite care and had a change in code status recorded in the electronic medical record. But no signed paper DNR order existed anywhere in the building. The director of nursing told LPN A to begin CPR. LPN A did not move.
LPN B arrived at the nurses station and found LPN A still standing there. LPN B took LPN A with her, and the two moved the resident to the floor where LPN A finally began compressions. While that was happening, LPN B took a call from the hospice physician, who said a staff member was on the way to the facility with a signed DNR document. LPN B understood that CPR had to continue until that physical document was in hand.
EMS arrived, took over, and pronounced the resident dead at 9:01 a.m. The hospice worker arrived with the signed DNR at the same moment.
LPN A later told investigators that the electronic record showed the resident as DNR and that she felt hospice should have resolved the paperwork before the resident arrived for respite care. She blamed the confusion on how hospice handled the status change.
The facility's own medical director did not accept that reasoning. He said staff were required to perform CPR unless a signed DNR was physically present, and that this was exactly that situation.
LPN A's personnel file documented the incident as a violation of the employee handbook's codes of conduct. The file noted she had failed to initiate life-saving measures despite explicit direction from her supervisor.
The event lasted somewhere between ten and fifteen minutes, by LPN A's own account. For that stretch, while a resident's heart was not being compressed, a nurse stood at a station and washed her hands.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Armour Oaks Senior Living Community from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
ARMOUR OAKS SENIOR LIVING COMMUNITY in KANSAS CITY, MO was cited for violations during a health inspection on May 28, 2026.
The resident at Armour Oaks Senior Living Community was on hospice respite care and had a change in code status recorded in the electronic medical record.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.