Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Crown Rehab And Healthcare Center during CMS and state inspections, most recent first.
The facility did not properly notify residents or their representatives about care plan meetings, as required by policy. For three sampled residents, there was no documentation of notification or evidence that they or their families were invited to participate in care planning. Staff interviews confirmed that while notifications were intended to be given, no records were kept to verify this process.
The facility did not complete annual evaluations for two CNAs and failed to provide the required twelve hours of annual in-service education for four CNAs, as shown by documentation and staff interviews. There was no clear process for auditing or tracking these requirements, and a policy for CNA evaluations was not provided when requested.
Multiple residents reported receiving cold or lukewarm meals, with test trays confirming that hot foods were served below required temperatures. Staff interviews revealed that food temperatures were only checked while in the steam table and not after plating, leading to ongoing complaints about cold food from residents in both their rooms and the dining area.
Surveyors found that kitchen shelves and ceiling vent covers were not properly cleaned, with rust and grime present on a walk-in cooler shelf and four vent covers over food and dishwashing areas. Staff interviews revealed confusion over cleaning responsibilities, and documentation of recent cleaning was not provided. These unsanitary conditions potentially affected all residents consuming food from the kitchen.
The facility failed to ensure timely and properly documented TB testing for three residents, with missing dates for test readings and delayed administration of tests. Additionally, staff did not follow proper infection control protocols during incontinence and perineal care for several residents, including failing to change gloves and perform hand hygiene between tasks, and handling clean items with contaminated gloves. Staff interviews confirmed these practices were inconsistent with facility policy.
A resident with major depressive disorder, bipolar disorder, and a traumatic brain injury was admitted without a completed or retained PASRR screening, as required for individuals with serious mental illness or intellectual disability. The facility did not obtain the necessary documentation from the previous facility or complete a new PASRR at admission, despite the resident's documented cognitive and behavioral issues.
Two residents who were dependent on staff for ADLs did not receive showers at least twice weekly as required, with documentation showing only one shower per week or missed weeks. Both residents expressed a desire for more frequent showers, and one reported incomplete daily peri care. Staff interviews revealed that showers were not consistently provided when the shower aide was unavailable, and the facility could not produce a bathing policy when requested.
A resident receiving hospice care did not have proper communication and coordination between the facility and the hospice provider. Staff relied on verbal reports, lacked written documentation of hospice visits, and were generally unaware of how to access hospice records or follow instructions in the hospice binder, resulting in incomplete documentation and coordination of care.
A resident with impacted cerumen and abnormal ear exam results did not receive recommended Debrox drops or cerumen management after an audiology evaluation. Despite the audiologist's documented recommendations, there were no corresponding physician orders or treatments administered, and the care plan did not address hearing issues. Interviews with staff and the resident revealed a lack of awareness and follow-up regarding the need for ear wax removal.
A resident with peripheral vascular disease and limited mobility experienced ongoing issues with thickened, overgrown toenails, dry and cracked feet, and a toe infection. Despite repeated documentation of these conditions by CNAs and nurses, there was no evidence of timely podiatry referral or appropriate foot care orders, and the care plan did not address these needs. Staff interviews revealed delays in podiatry scheduling and confusion about Medicaid status, while the resident reported worsening foot conditions and no podiatry visits since admission.
Two nurse assistants were allowed to provide direct care beyond four months of employment without completing the required CNA training or obtaining certification. Both staff and management confirmed awareness of the four-month requirement, but monitoring failed to prevent the deficiency, and no relevant policy was provided when requested.
Failure to Notify Residents and Representatives of Care Plan Meetings
Penalty
Summary
The facility failed to notify residents or their representatives of care plan meetings for three out of twenty sampled residents. According to the facility's policy, residents and/or their representatives should be invited to care plan meetings, and written summaries of the care plan should be provided, with evidence of this maintained in the medical record. However, review of the electronic health records for the affected residents showed no documentation that notifications were given. Interviews with residents and a family member revealed uncertainty about when care plan meetings occurred or if they had been invited, and some residents reported not attending or being aware of any care plan meetings. Staff interviews indicated that the Social Services Designee (SSD) was responsible for notifying residents and families, typically by leaving letters at the bedside or making phone calls. However, the SSD confirmed that no progress notes or documentation were made to verify that notifications were provided. The Administrator also acknowledged that there was no documentation of care plan invitations and that the SSD did not have access to the electronic notification system. This lack of documentation and communication resulted in the deficiency related to resident participation in care planning.
Failure to Complete CNA Annual Evaluations and Required In-Service Education
Penalty
Summary
The facility failed to complete annual evaluations for two Certified Nursing Assistants (CNAs) and did not provide the required twelve hours of annual in-service education for four CNAs, as evidenced by record review and staff interviews. Specifically, CNA N and CNA P did not have annual evaluations documented for the required years, and CNAs L, N, O, and P each had only three hours of in-service training documented, falling short of the twelve-hour requirement. The facility's policy required all certified nursing personnel to complete at least twelve hours of in-service education annually from their date of hire, and staff who did not meet this requirement were to be removed from the schedule. However, documentation showed that these requirements were not met for the sampled CNAs. Interviews with the Administrator, DON, and Payroll/Human Resources revealed a lack of clear auditing and tracking processes to ensure annual evaluations and in-service education were completed. The DON stated that he/she prepared the evaluations and expected them to address knowledge, reliability, goals, and weaknesses, but was unaware of who was responsible for auditing their completion. Payroll/Human Resources indicated that annual evaluations were tracked between their department and the Administrator, but also noted that CNAs would usually request their evaluations. A policy for CNA evaluations was requested by surveyors but was not provided by the facility.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at safe and appetizing temperatures to residents, as evidenced by multiple observations, interviews, and review of facility records. Test trays revealed that hot foods, including turkey slices, vegetables, and casseroles, were served below the facility's required temperature of 135 degrees Fahrenheit, with recorded temperatures ranging from 116 to 131.1 degrees Fahrenheit. Pureed foods and desserts were also served below the required temperatures. Resident council minutes from several months documented repeated complaints about cold food, and multiple residents reported receiving cold or lukewarm meals, both in their rooms and in the main dining area. Staff interviews confirmed that residents frequently complained about cold food, and staff sometimes attempted to reheat meals in microwaves or provide new trays upon request. The Dietary Manager acknowledged that food temperatures were only checked while food was in the steam table and not after plating, despite a thirty-minute delay between plating and serving the last resident. This practice resulted in food cooling before it reached residents, leading to ongoing dissatisfaction and repeated complaints documented by both residents and staff.
Failure to Maintain Kitchen Cleanliness and Sanitation Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain cleanliness in the kitchen, specifically by not removing rust and grime from a shelf in the walk-in cooler and not cleaning four ceiling vent covers located over the hot drink preparation area and the hand washing sink/dishwashing areas. The shelf inside the walk-in cooler was found to be covered in a dark sticky substance and had rusted areas, while the vent covers were discolored with dark brown or black grime, dust, or debris. These conditions were directly observed during a kitchen inspection and potentially affected all residents who consumed food prepared in the kitchen. Interviews with facility staff revealed a lack of clarity regarding responsibilities for cleaning and maintaining these areas. The Dietary Manager stated that kitchen staff were responsible for wiping down shelves but was unaware of who should remove rust. The Maintenance Director indicated that maintenance handled rust removal and vent cleaning, but was not aware of the current condition of the vent covers and could not provide documentation of recent cleaning. The Regional Dietary Manager and Administrator both acknowledged the presence of rust and dirt on the vent covers, confirming the deficiency.
Deficient TB Screening and Infection Control Practices
Penalty
Summary
The facility failed to ensure accurate and timely tuberculosis (TB) testing for three residents, as required by its own policy. Specifically, TB skin test records for several residents did not include the date the test was read, and in one case, the second step of the two-step TB test was administered outside the recommended timeframe. Additionally, one resident received the TB skin test five days after admission, rather than upon admission as required. The facility's TB screening policy lacked clear instructions on when to read the skin test and how to document the findings, contributing to these deficiencies. Infection control practices during incontinence and perineal care were not consistently followed for multiple residents. Observations revealed that staff members, including CNAs, performed resident transfers, incontinence care, and handling of personal and room items without changing gloves or performing hand hygiene between tasks. Staff were seen using the same pair of gloves to touch soiled briefs, clean residents, handle clean supplies, adjust clothing, and even offer beverages, without removing gloves or sanitizing hands. In some cases, staff exited resident rooms and touched common surfaces without performing hand hygiene. Interviews with staff and consultants confirmed that the observed practices did not align with facility policy or standard infection control protocols. Staff acknowledged that gloves should be changed and hands sanitized between dirty and clean tasks, and that supplies should be prepared in advance to avoid contamination. However, the observed actions demonstrated a lack of adherence to these protocols, resulting in multiple instances of improper hand hygiene and glove use during resident care.
Failure to Complete and Retain Required PASRR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the completion, submission, and retention of a Level I Pre-Admission Screening and Resident Review (PASRR) for a resident with multiple mental health diagnoses, including major depressive disorder, bipolar disorder, and a history of traumatic brain injury. Upon review, there was no PASRR documentation in the resident's electronic health record, despite the resident having been admitted with conditions that require such screening. The resident's care plan documented cognitive impairment, behavioral symptoms, and communication problems related to their diagnoses, but did not reference a current PASRR. Interviews with the Social Service Designee and the Administrator revealed that the resident had a PASRR completed in 2004 at a previous facility, but no copy was obtained at the time of admission to the current facility in 2020. Efforts to retrieve the original PASRR from the Central Office Medical Review Unit were unsuccessful due to the age of the document. The facility was advised to complete an updated PASRR, but this was not done at the time of admission, resulting in a failure to comply with federally mandated screening requirements for residents with serious mental illness or intellectual disability.
Failure to Provide Required Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living (ADLs) received bathing or showers at least twice weekly, as per their care plans and stated preferences. Both residents were cognitively intact and dependent on two staff members for bathing due to significant physical and cognitive impairments, including hemiplegia, traumatic brain injury, morbid obesity, muscle wasting, and arthritis. Review of shower and skin condition reports over a six-week period showed that each resident received only one shower per week, with some weeks missed entirely, rather than the required two showers per week. Interviews with the affected residents revealed that they were unsure of when they last received a shower and expressed a desire for at least two showers per week. One resident also reported not receiving complete perineal care daily, stating it occurred only about once a week. These statements indicate that the residents' preferences and care needs were not consistently met regarding personal hygiene. Staff interviews confirmed that showers were typically provided by a designated shower aide, but when the aide was unavailable, CNAs did not routinely provide showers unless the resident was incontinent. Staff also described procedures for offering showers and documenting refusals, but the records and resident interviews indicated that these procedures were not consistently followed. Additionally, the facility was unable to provide a policy for showers/bathing when requested by surveyors.
Failure to Ensure Communication and Coordination with Hospice Provider
Penalty
Summary
The facility failed to ensure proper communication and coordination of care with a hospice provider for a resident who was severely cognitively impaired and receiving hospice services. The facility's End of Life Care policy did not include instructions on how to communicate and coordinate with hospice providers. Review of the hospice communication book revealed that, while it contained instructions for accessing hospice electronic records and admission information, it lacked documentation of hospice provider visits or written communication regarding those visits. Staff interviews confirmed that communication with hospice was primarily verbal, with no written documentation of visits in the facility's electronic medical records, and staff were generally unaware of how to access hospice records or utilize the instructions provided in the hospice binder. Multiple staff members, including LPNs and a Certified Medication Technician, indicated they did not know how to access hospice documentation or were unaware of the written instructions available in the hospice binder. The administrator stated that staff should document changes in orders and could access the hospice provider's electronic portal, but staff interviews revealed this was not being done. As a result, there was a lack of documented communication and coordination between the facility and the hospice provider regarding the resident's care.
Failure to Follow Audiologist Recommendations for Cerumen Management
Penalty
Summary
A deficiency occurred when the facility failed to follow up on audiologist recommendations for a resident who was cognitively intact and had been identified as having impacted cerumen in both ears, with abnormal ear exam results in the right ear. The audiologist recommended the use of Debrox drops and adherence to the facility's cerumen management protocol. However, a review of the resident's Physician Order Summary (POS) and Medication Administration Record (MAR)/Treatment Administration Record (TAR) for the months following the audiology report showed no orders or administration of Debrox drops or any cerumen treatment. The resident's care plan did not include information regarding hearing issues, and subsequent MDS assessments continued to indicate adequate hearing without addressing the audiologist's findings. Interviews with the resident and various staff members, including CNAs, a CMT, an LPN, the Social Services Designee, and the Director of Nursing, revealed a lack of awareness and follow-through regarding the audiologist's recommendations. The resident expressed a desire to hear better and to return to the audiologist, while staff were generally unaware of the need for ear drops or the resident's hearing issues. The DON confirmed that the audiologist's recommendation for ear wax removal drops was not added to the physician order sheet or administered, and stated that nurses were expected to follow up with the physician to add such orders.
Failure to Provide Necessary Foot Care and Podiatry Referral
Penalty
Summary
The facility failed to provide necessary foot care and treatment for one resident with a history of peripheral vascular disease and limited mobility. The resident was admitted to the facility and was cognitively intact, requiring substantial assistance with lower body dressing and footwear, and did not ambulate. Facility policy required that residents with circulatory impairment or thickened, difficult-to-cut toenails be referred to a podiatrist, and that any changes in the skin around the nail be reported to the physician. Despite multiple documented observations by CNAs and nurses over several weeks indicating the resident had swollen, dry, cracked feet, overgrown and thickened toenails, and a sore, infected toe, there was no evidence in the electronic health record of podiatry involvement or orders for foot care. The resident's care plan did not address foot or toenail care, and there were no physician orders for treatment of the feet or toenails. The resident's infection was eventually treated with antibiotics after assessment by a nurse practitioner, but ongoing issues with thickened, overgrown toenails and dry, scaly skin persisted without podiatry intervention. Interviews with staff revealed confusion regarding the scheduling of podiatry services, with delays attributed to Medicaid status and paperwork processing. The resident reported not having seen a podiatrist since admission and noted worsening of foot and toenail conditions during their stay. Observations confirmed the resident's toenails remained severely thickened and overgrown, with scaly, flaking skin and evidence of previous injury or infection, indicating a lack of timely and appropriate foot care as required by facility policy.
Failure to Ensure Timely CNA Training and Certification for Nurse Assistants
Penalty
Summary
The facility failed to ensure that two nurse assistants (NAs) completed the Certified Nurse Assistant (CNA) training program within four months of employment, as required. Review of facility records showed that both NAs had hire dates that set their CNA training completion deadlines within a four-month window, but both continued to work direct hands-on care shifts beyond these deadlines without having completed the required training or obtaining certification. Both NAs confirmed in interviews that they were aware of the four-month requirement but had not completed the CNA program or become certified by the deadline. Interviews with the Director of Nursing (DON) and Payroll/Human Resources staff revealed that responsibility for monitoring CNA training and certification deadlines was assigned to Payroll/Human Resources. Despite this, both NAs were allowed to continue working in direct care roles past the four-month limit without certification. Additionally, when requested, the facility did not provide a policy regarding NA training and certification by the exit date of the survey.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 239 citations issued within 25 miles in the last 12 months — including the 9 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 Harrisonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow View Health & Rehabilitation | 0.7 mi | ★★★★★ | 15 | 0 |
| Golden Years Center For Rehab And Healthcare | 2 mi | ★★★★★ | 37 | 3 |
| Aspire Senior Living Pleasant Hill | 9.3 mi | ★★★★★ | 2 | 0 |
| Sunrise Nursing & Rehabilitation | 12 mi | ★★★★★ | 1 | 0 |
| Foxwood Springs Living Center | 14 mi | ★★★★★ | 1 | 0 |
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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.