Golden Years Center For Rehab And Healthcare
GOLDEN YEARS CENTER FOR REHAB AND HEALTHCARE in HARRISONVILLE, MO — inspection on October 29, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an
dumb.-He/She did not want LPN D to be his/her nurse anymore. -He/She wanted to move rooms so the LPN would not be his/her nurse.-He/She really liked his/her roommate and hated to move rooms, but he/she did not want LPN D to be his/her nurse ever.-The LPN had really hurt his/her feelings.-The LPN had treated him/her mean.-The resident was upset, but was not crying about the situation with the LPN.-The resident appeared hurt by the event. -He/She told the administrator when asked about the incident.
During an interview on 10/29/25 at 10:30 A.M., LPN D said:-The resident started to get agitated.-When the nurse walked down the hall the resident was yelling. -CNA D said the resident was yelling and being disrespectful.-The resident was yelling and saying that cares were not being done. -The resident said the CNA was lying and he/she never said that. -The resident said he/she was dumb and called the LPN dumb.-He/She responded sarcastically yeah you are dumb, but did not mean it.-The resident said he/she did not want to be LPN D's friend anymore. -The resident came and told the LPN later that the resident was sorry.
During an interview on 10/29/25 at 10:50 A.M., Admissions Coordinator said:-He/She did not witness the event, he/she just filed out the grievance. -The resident reported that LPN D called him/her dumb and would not give him/her any medications or bring the resident anymore puzzles. -The resident was really hurt and would not be LPN D's friend anymore. -The resident wanted to move rooms so he/she would not have LPN D as a nurse. -It was never appropriate to call a resident dumb.-The resident was visibly upset and crying. -The behaviors were out of character for the resident.
During an interview on 10/29/25 at 11:01 A.M., CMT C said:-He/She came into the resident's room after the incident.-The resident was visibly upset and crying.-The resident said that LPN D had called him/her dumb.-The resident reported to him/her the LPN told the resident to not ask him/her for anything.-The resident had issue with being called dumb, because the resident said that is what his/her father had always called the resident. -The resident was visibly angry and upset when telling them about the incident.-The resident did not complain about staff.
During an interview on 10/29/25 at 11:50 A.M., CNA D said:-After lunch the resident wanted to be laid down.-He/She told the resident that he/she needed to find another person to help.-He/She found LPN D to help lay the resident down.-When the LPN got in the room and started to help the resident into bed, the nurse started to yell at the resident that the resident was trying to get him/her fired. -Once the resident was in bed he/she told the LPN to leave the room that he/she could finish.-The LPN kept talking to the resident and said what are you dumb.-He/She got the LPN out in hall and the LPN said the bitch (referring to the resident) was trying to get him/her in trouble.
During an interview on 10/29/25 at 12:01 P.M., Interim Director of Nursing said:-If a staff member called a resident dumb that would be a violation of the resident's dignity. -An investigation had been started regarding the incident with LPN D and Resident #13.-If LPN D violated Resident #13's dignity then the LPN would be terminated. -No staff member should have ever violated the resident's dignity.
265349 10/29/2025
Golden Years Center for Rehab and Healthcare 2001 Jefferson Parkway Harrisonville, MO 64701
During an interview on 10/20/25 at 4:00 P.M., Certified
#6.-Resident #4 was running and pushing Resident #6 in his/her wheelchair through the hallway and around a corner.-Resident #6 was scared and waving his/her arms.-Housekeeper B intervened to stop Resident #4 from pushing Resident #6.-Resident #4 became angry and hit Resident #6 hard on the back of the head and the shoulders.-Resident #4 hit Resident #6 two or three times.
During an interview on 10/21/25 at 11:14 A.M., Resident #6's responsible party said:-He/She was unhappy about Resident #6 being abused in the facility by another resident.-He/She witnessed Resident #4's behaviors and they were scary.-Resident #6 feared Resident #4.-Other residents in the facility feared Resident #4.-He/She was in a wheelchair himself/herself due to a recent health problem. He/she would have been terrified if what happened to Resident #6, happened to him/her.-He/She believed the physical contact made to Resident #6 by Resident #4 caused the resident pain.-He/She believed the incident caused the resident caused emotional sadness and the resident trauma. -He/She knew Resident #6 well and knew that he/she was scared and traumatized by the incident.-Resident #6 suffered from depression and he/she felt the incident could make the resident's depression worse.
During an interview on 10/28/25 at 9:13 A.M., Interim Administrator A and the Corporate DON said:-He/She would expect all residents to be kept safe and free from abuse in the facility.-It was the responsibility of all staff members to ensure the safety and wellbeing of each resident.-He/She would expect all residents to free from abuse in the facility. 2645193, 2646488, 2642955, 2633865, 2636127, 2640626, 2646855
265349 10/29/2025
Golden Years Center for Rehab and Healthcare 2001 Jefferson Parkway Harrisonville, MO 64701
During an interview on 10/22/25 at 4:08 P.M., Corporate DON said:-He/She was contacted by LPN C and asked about the wound care orders for the resident.-He/She instructed LPN C to reach out to the surgeon to clarify the wound care orders.-The surgeon was never notified by LPN C.
During an interview on 10/22/25 at 4:12 P.M., LPN C said:-The administrator terminated him/her before he/she could follow through with clarifying the wound care orders.-He/She would have expected the DON and the administrator to follow through with ensuring that the resident received his/her wound care.-There was a message on What's App from the administrator where he/she posted an email from the resident's transplant RN and asked staff to follow-up but as far as he/she knew, no one ever did. -The DON was supposed to follow up with the resident's organ transplant team to coordinate care between the transplant team and the facility.
During an interview on 10/22/25 at 9:30 A.M., DON said:-He/She never knew that a transplant team member was trying to reach a clinical nurse in the facility to coordinate care for the transplant resident.-He/She would have expected good communication to occur between the transplant team and the facility staff.-The administrator never told him/her that anyone from the transplant team or hospital staff was trying to reach a clinical nurse-He/She denied receiving a message from staff regarding the communication with the resident's transplant nurse. -He/She would expect residents to receive their wound care as ordered.-He/She was not aware that the resident was not receiving his/her wound care as ordered. -He/She was not sure who was responsible for completing wound care for the residents.
During an interview on 10/22/25 at 4:50 P.M., DON said:-He/She never received a message from the administrator on Whats App or any other means asking him/her to check up on the transplant resident.-He/She was never instructed in person by the administrator to contact the resident's transplant team for coordination of care.
Note: When it was told to the DON that an email was observed from transplant team and the resident's family member that was addressed to the administrator and then forwarded to him/her, the DON said:-He/She was working the floor on the day the administrator sent the emails about the resident and was flustered.-The resident was still in the building on the day the emails were received, but he/she forgot to take care of it because he/she worked the floor that day.-He/She felt bad and knew that he/she dropped the ball.-The administrator never followed up with him/her to ensure that the clinical team reached out to the transplant team.
During an interview on 10/23/25 at 10:42 A.M., the ADON said:-He/She was never instructed to contact the resident's transplant team.-He/She was not aware that the resident was not receiving his/her medication.-He/She was not aware that the resident was not receiving his/her wound care orders.-He/She would expect wound c
265349 10/29/2025
Golden Years Center for Rehab and Healthcare 2001 Jefferson Parkway Harrisonville, MO 64701
Review of the
resident received a PRN medication for anxiety on [DATE].
Review of the resident's administration note, dated [DATE] at 7:48 A.M., showed the resident administered Vistaril (an antihistamine that has received FDA approval for the short-term management of anxiety and tension) 25 mg for anxiety.
Review of the resident's EMR on [DATE], showed no nursing note documenting the resident's behaviors or why the resident received the as needed medication for anxiety on [DATE].
Review of the resident's administration note, dated [DATE] at 12:23 P.M., showed the resident administered Vistaril 25 mg for anxiety.
Review of the resident's EMR on [DATE], showed no nursing note documented regarding the resident's behaviors or why the resident received an as needed medication for anxiety on [DATE].
Review of the resident's health status note, dated [DATE], showed the resident reported to staff that he/she was having suicidal ideation and thoughts of harming himself/herself.
The resident requested to be sent to the hospital.
The resident refused his/her medication.
Review of the resident's behavior note, dated [DATE], showed:-The resident returned from the hospital in 4-point restraints, due to hitting the staff on the ambulance and at the hospital.-The resident was yelling and cussing at staff and other residents.-The resident went out the door and tried to go down the driveway.-The resident was returned to the building.-The resident attempted to leave the facility numerous more times.-The resident threw a phone across the room-The resident was threatening to hit staff and other residents.-The resident was yelling that he/she wanted to die.-The resident attempted to throw his/her urinary catheter bag at staff.-The resident was sitting naked in the front lobby and refused to put clothes on.-The resident was threatening to put his/her fist through the glass door and cut herself.-The DON was notified of the resident's behaviors.
Review of the resident's EMR on [DATE], showed:-No care plan updates or interventions were completed by staff on [DATE].-No behavior monitoring documented by staff on [DATE].-No nonpharmacological intervention documented by staff on [DATE].-No increased supervision (15 minute or one-on-one) interventions were initiated on [DATE] after the resident reporting having suicidal ideation and increased behaviors.
Review of the resident's behavior note, dated [DATE] at 4:10 A.M., showed:-The resident refused to take medication and eat meals.-The resident yelled and cussed at staff.-The resident attempted to leave out of the door next to his/her room at the end of the hall.-The resident attempted to go out of the front door.-The resident attempted to throw his/her catheter bag at staff.-The resident yelled, I want to die.
Review of the resident's behavior note, dated [DATE] at 8:25 A.M., showed:-The resident had behaviors throughout the entire night.-The resident requested to go to the hospital.-Staff informed the resident that he/she could not go to the hospital.-Staff informed the resident that he/she needed something medically wrong with him/her to go the hospital.-The resident stated, Well then maybe I will just kill myself.
Review of the resident's EMR on [DATE], showed:-No care plan updates or interventions were completed by staff on [DATE].-No behavior monitoring documented by staff on [DATE].-No nonpharmacological intervention documented by staff on [DATE].-No increased supervision (15 minute or one-on-one) interventions were initiated on [DATE] after the resident reporting having suicidal ideation and increased behaviors.
During an interview on [DATE] at
265349 10/29/2025
Golden Years Center for Rehab and Healthcare 2001 Jefferson Parkway Harrisonville, MO 64701
Review of Resident #7's admission Record showed the resident admitted to the facility on [DATE] with diagnoses of:-Schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors).-Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts).-Generalized Anxiety (a chronic mental health condition characterized by excessive and persistent worry, tension, and nervousness).-Morbid obesity (body weight is more than 80 to 100 pounds above their ideal body weight).-Muscle weakness.
Review of the resident's PASRR, dated [DATE], showed:-The resident had mild mental retardation per the department of mental health.-The resident had depression and was withdrawn.-The resident had moderate amount of suspicion and paranoia.-The resident had hallucinations.-The resident had delusions.-The resident had moderate amount of abnormal thought processes.-The resident was controlled with medication.-The resident was non-compliant with medication.-The resident had limited insight with poor decision making skills.-It was recommended that the resident should reside in secure placement.-The resident had a legal guardian through the public administrator's office-The resident had the following diagnoses:--Major depressive disorder--General anxiety disorder with panic attacks--Post-traumatic stress disorder (PTSD- a mental health condition caused by very stressful, frightening or distressing events).--Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder).--Bipolar disorder (a mental health condition characterized by extreme mood swings, alternating between periods of mania (elevated mood) and depression (low mood).--Schizophrenia--Borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life. It includes a pattern of unstable, intense relationships, as well as impulsiveness and an unhealthy way of seeing themselves).-The resident was diagnosed with PTSD at the age of 19 which causes him/her to constantly worry and be anxious.-The resident had a history of auditory and visual hallucinations.-The resident had nightmares and flashbacks of prior traumatic events that happened in his/her life.-The resident reported frequent worry, muscle tension, impaired concentration, and difficulty focusing.-The resident had suicidal ideation dating back to the age of 25.-The resident attempted to commit suicide in November of 2020 when he/she overdosed on a whole bottle of Valium (benzodiazepine- a group of medications classified as central nervous system (CNS) depressants, meaning they slow down the nervous system).-The overdose attempt required hospitalization.-The resident had multiple inpatient psychiatric admissions through the years dating back to 1993.-The resident became physically and verbally aggressive towards others and herself when he/she had a urinary tract infection.-The resident was an elopement risk.-The resident required 24 hour per day nursing supervision oversight to assure his/her safety.-The resident required ongoing medical and psychiatric follow[TRUNCATED]
265349 10/29/2025
Golden Years Center for Rehab and Healthcare 2001 Jefferson Parkway Harrisonville, MO 64701
During an interview on 10/23/25 at safety 12:57 P.M., the Administrator said: -He/She was responsible for ensuring that the facility was managed in a manner to maintain the highest practicable, physical, mental, and psychosocial
patient.-He/She was not aware that the resident was not receiving his/her medication.-He/She would have expected all medication to be administered and no doses to be missed.
During an interview on 10/23/25 at 12:55 P.M., the Chief Operating Officer (COO) said: -He/She would expect that all residents received their medication and treatments as ordered.-He/She would expect the clinical team and the administrator ensured safe medication administration of all of a resident's medication.-He/She expected staff to coordinate care with transferring facilities to ensure that resident's medication were all transcribed and continued.Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J.
Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at that time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements At the time of exit, the severity of the deficiency was lowered to the D level.
This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address the Class I violation(s).Complaint numbers: 2645193, 2646488, 2642955, 2633865, 2636127, 2640626, 2646855, 2648264
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.