Silverstone Place
SILVERSTONE PLACE in ROLLA, MO — inspection on November 20, 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
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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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.