Golden Age Living Center: Missing Controlled Meds - MO
That is what federal inspectors documented during a November 10 complaint inspection at the facility. A resident's controlled drug count came up wrong. The Director of Nursing looked into it. And then, by her own admission, she documented nothing — not on the controlled medication sheet, not in the resident's chart, not anywhere.
The discrepancy was first noticed on November 3. The DON said she believed one of the night nurses caught it. By then, the counting error had already sat undetected for four days. The DON traced the problem back to October 30, when two nurses counted the resident's medications on admission. The resident had brought the controlled drugs from home, and those two nurses were responsible for verifying the count at the door.
The DON interviewed both nurses. She said she determined they had counted incorrectly at admission. But she acknowledged she could not say whether the pills were miscounted or taken. That distinction — whether a counting error or missing drugs — is exactly what a documented investigation is supposed to resolve. She never resolved it.
She also never asked staff why the discrepancy went unnoticed from October 30 to November 3. She notified the administrator. The administrator told her nothing further. And there it stopped.
The DON told inspectors she did not know the facility's own policy on controlled medication count discrepancies.
That admission sat at the center of a cascade of failures inspectors documented. A certified medication technician, identified in the report as CMT B, told inspectors that an unidentified CMT had caught the count error the weekend before it was formally flagged. CMT B said he or she did not know who investigated it, did not know what documentation had been completed, and could point only to three circled doses on the controlled drug record sheet — no narrative, no incident note, no name attached to the circles.
CMT B said nurses are responsible for investigating medication count issues.
LPN A, interviewed the same morning, agreed that a CMT catching a count error should notify a nurse, who would then review the records and investigate. LPN A said the DON would handle it if the discrepancy could not be resolved. But LPN A said he or she did not know how or where count errors were supposed to be documented. And LPN A said he or she was not aware of any resident's medication counts needing review or investigation at all.
So the CMT who first noticed the error apparently told no one, or told someone who told no one. The count sat wrong for days. When a night nurse finally caught it, the DON investigated and reached a conclusion she couldn't fully support, then left no record that any of it happened.
The administrator told inspectors the DON is responsible for documenting medication discrepancies on the medication sheet and in the resident's progress notes. He or she said the DON had assured him or her the medications were simply miscounted at admission. The administrator said he or she was aware staff had not followed facility policy. He or she could not recall which resident was involved.
The controlled drug record sheet showed three circled doses. That is the only mark anyone left.
Whether those pills were miscounted or taken, no one at Golden Age Living Center can now say with certainty. The investigation that might have answered that question was conducted, concluded, and then erased by the simple act of writing nothing down.
The resident whose medication was at the center of all of this is identified in the inspection report only by implication — someone who arrived at the facility on October 30 carrying controlled drugs from home, handed them over to two nurses who got the count wrong, and then spent days in a building where the people responsible for tracking that medication either didn't notice or didn't say anything.
Inspectors rated the violation as carrying minimal harm or potential for actual harm, affecting few residents. The complaint that triggered the inspection is logged under number 2664063.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Age Living Center from 2025-11-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
GOLDEN AGE LIVING CENTER in STOVER, MO was cited for violations during a health inspection on November 10, 2025.
That is what federal inspectors documented during a November 10 complaint inspection at the facility.
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.