Golden Years Center for Rehab and Healthcare

In the surveyor’s words

From the most serious findings on record at Golden Years Center for Rehab and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF742Oct 29, 2025

  Based on observation, interview and record review, the facility failed to provide treatment and behavioral health services for three sampled residents (Resident #4, Resident #7, and Resident #3) who had known behavioral health history and mental health diagnoses. The facility staff failed to implement a PASRR for Resident #4 and failed to create a plan of care for Resident #3 and Resident #4 to provide interventions for behaviors. The facility failed to transcribe, order, and administer Resident #4's psychotropic medications from [DATE] - [DATE] followed by an escalation of aggressive behaviors. […]

• Immediate jeopardy, isolatedF684Oct 29, 2025

  Based on interview and record review, the facility failed to meet the medical needs of two of three sampled residents (Resident #12 and Resident #4). On 10/15/2025, Resident #12 admitted to the facility with diagnoses including end stage renal disease and post operative right renal kidney transplant. The facility failed to give the resident their ordered anti-rejection medication, failed to provide wound care for their surgical wound for two and a half days, and failed to notify the resident's physician and transplant physician of the missed medications and wound care. […]

• Immediate jeopardy, isolatedF760Oct 29, 2025

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident #12) was free from a significant medication error. The facility failed to order and administer Resident #12's antirejection medication after the resident admitted to the facility post kidney transplant. Resident #12 did not receive ordered medications for immunosuppression (a state in which the body immune system is weekend and less effective in fighting infection) on 10/15/25 and 10/16/25. […]

• Actual harm, isolatedF600Oct 29, 2025

  Based on interview and record review, the facility failed to ensure two sampled residents (Resident #5 and Resident #6) were free from physical abuse when Resident #4 verbally abused and attempted to physically abuse Resident #5 which caused the resident to fall and resulted in feelings of embarrassment and humiliation for Resident #5. In addition, Resident #4 physically abused Resident #6 which caused Resident #6 pain and the need to be sent to the hospital for evaluation. Thirteen residents were sampled. The facility census was 90. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to keep the walk-in freezer floors clean; failed to ensure food preparation equipment were kept in a sanitary condition; failed to maintain plastic cutting boards and plate covers in good condition to avoid food safety hazards (cross-contamination); and failed to separate damaged foodstuffs, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 67 residents with a licensed capacity for 119 residents at the time of the survey. 1. Observation on 1/21/26 between 12:29 P.M. […]