Silverstone Place
Inspection Findings
F-Tag F0760
F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Administration Record verses the resident and the medication. He/She said he/she should have verified the resident's last name and date of birth prior to administering the insulin. CMT B said he/she did not ask the resident's last name and knew he/she should have asked. He/She said the two residents had just been admitted to the facility.During an interview on 11/20/24 at 8:28 A.M., Resident #1 said staff did give her the wrong medication, he/she said he/she does not know a lot of details, but staff scrambled to get him/her sugar because the insulin took his/her sugar too low. He/She said staff checked on him/her constantly.
He/She said he/she is a diabetic, but he/she does not take insulin just metformin. He/She said the medication error was scary, but staff handled it well.During an interview on 11/20/25 at 8:55 A.M., the administrator said CMT B gave Resident #1 Resident #2's insulin, when resident #1 does not receive insulin for his/her diabetes diagnoses. He/She said the residents have the same first name and were admitted about the same time and across the hall from each other. He/She said CMT B states she verified
the residents name, and the resident said yes. He/She said the resident refused to go to the hospital.
He/She said the resident was given sugar and was place on one-on-one monitoring for over 24 hours.
He/She said there was a full investigation into the medication error and staff were in serviced on insulin administration and the seven rights of medication administration.During an interview on 11/20/25 at 9:45 A.M., The DON said he/she expects all staff administering medication to follow the seven rights of medication administration, and if they have questions they need to verify further. He/She said the medication error was not intentional, Resident #1 and Resident #2 share the same first name and the CMT was confused. He/She educated staff for insulin administration and the seven rights of medication administration.2626672
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SILVERSTONE PLACE in ROLLA, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ROLLA, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SILVERSTONE PLACE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.