Golden Age Living Center
GOLDEN AGE LIVING CENTER in STOVER, MO — inspection on November 10, 2025.
Found 1 citation. 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
he/she was aware the resident's medication count was incorrect. CMT B said an unidentified CMT had recognized a medication count error the weekend prior. CMT B said he/she did not know who investigated the count error or what documentation was completed other than the three circled doses on the controlled drug record sheet. CMT B said the nurses are responsible for investigating and documenting medication count issues.
During an interview on 11/10/2025 at 11:41 A.M., Licensed Practical Nurse (LPN) A said a CMT or nurse taking over the medication cart is responsible for ensuring medication counts are correct.
LPN A said CMT's would be expected to notify a nurse of incorrect medication counts and the nurse would review the records and investigate. LPN A said the nurse would inform the DON if the discrepancy could not be resolved. LPN A said he/she did not know how or where count errors were documented, but he/she thought the DON would document the issue. LPN A said he/she was not aware of residents' medication counts needing review or investigation.
During an interview on 11/10/2025 at 11:48 A.M., the DON said when a resident brings controlled medications from home two nurses count the medications to verify counts.
The DON said staff should count pills at every shift change and if medication counts did not match, he/she would interview staff to identify the problem.
The DON said he/she thought one of the night nurses noticed the incorrect pill count on 11/03/25.
The DON said he/she spoke with the two nurses who counted the resident's medication on admission, and he/she determined the nurses counted incorrectly but he/she could not say if the pills were counted incorrectly or taken.
The DON said he/she never asked staff why the medication discrepancy was not identified until 11/03/25 after he/she determined a counting error took place on 10/30/25.
The DON said he/she notified the administrator but did not receive any further instruction from the administrator.
The DON said he/she did not know the facility's policy related to count discrepancies in controlled medications.
The DON said he/she did not document his/her investigation and did not document the discrepancy on the controlled medication sheet or in the resident's chart.During an interview on 11/10/2025 at 12:03 P.M., the administrator said CMTs, and nurses should catch incorrect medication counts at shift change when they count the controlled medications.
The administrator said he/she expects all controlled medications to be counted accurately at every shift change.
The administrator said the charge nurse or DON should be notified of any discrepancies in the medication counts.
The administrator said the DON is responsible for investigating medication discrepancies and documenting his/her findings on the medication sheet and in the resident's progress notes.
The administrator said he/she was not aware the DON did not document the resident's medication count discrepancy or the result of his/her investigation.
The administrator said he/she was aware of an issue with one resident's medication count, but he/she did not recall which resident.
The administrator said the DON assured him/her the resident's medications were counted incorrectly when the resident was admitted .
The administrator said he/she was aware staff did not follow facility policy.
Complaint 2664063
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