Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silverstone Place during CMS and state inspections, most recent first.
A CMT administered another resident's insulin to a resident with diabetes managed by metformin, not insulin, after failing to properly verify the resident's identity. The error occurred because two residents had similar first names and were new admissions located near each other. The resident received 24 units of Novolog insulin without a physician's order, but did not experience immediate adverse effects.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required.
A nurse administered a Fentanyl patch intended for one resident to another, cognitively intact resident with congestive heart failure who did not have an order for Fentanyl. The error occurred when the LPN, unfamiliar with the day shift routine, failed to follow medication verification procedures and only realized the mistake during charting about 30 minutes later.
Facility staff failed to ensure dietary staff had the appropriate competencies and skills for kitchen sanitation. Observations showed the dishwashing machine operating below required temperatures, and items were not properly sanitized in the three-compartment sink. Interviews revealed insufficient training and lack of documented competency assessments.
Facility staff failed to thaw frozen food properly, store frozen food at safe temperatures, and allow cleansed dishes to air-dry before stacking. Observations showed improper thawing of meat, reach-in freezer temperatures above recommended levels, and wet pans being stacked in storage. Interviews revealed a lack of understanding and adherence to proper procedures.
The facility staff failed to perform Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks in accordance with their policy for six out of ten sampled staff members. Significant delays were observed, with some CBC results being received as late as 329 days after hire and EDL checks being performed up to 63 days after hire. The Human Resources Manager acknowledged the missing documentation and admitted that the policy had not been followed.
Facility staff failed to notify the Ombudsman of resident transfers to the hospital for five residents. Medical records and monthly transfer logs lacked documentation of these notifications. Interviews revealed confusion among staff about the notification process, and the facility did not provide a policy for Ombudsman notification.
Facility staff failed to provide written information about the bed hold policy to residents and/or their responsible parties during hospital transfers. This deficiency affected eight residents, with no signed bed hold agreements found in their medical records. Interviews revealed confusion among staff about who was responsible for this task.
Staff failed to document the dosage of insulin administered to three residents, despite facility policies requiring such documentation. The MARs for these residents showed multiple instances of undocumented dosages, and interviews revealed that the facility's electronic system was not set up to record this information.
Facility staff failed to maintain hot food temperatures at or above 120°F when serving hall trays to residents. Observations and interviews revealed that food items were consistently below the required temperature, and staff did not offer to reheat the food. The Dietary Manager and other staff members had inconsistent understandings of the required food holding temperatures, and there was a lack of proper training and communication.
The facility staff failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident experienced falls without consistent intervention, another had missing directions for essential equipment, and a third lacked seizure management instructions. Staff interviews revealed issues with care plan access and communication.
Medication Error Due to Improper Resident Identification
Penalty
Summary
Facility staff failed to ensure residents remained free of significant medication errors when a Certified Medication Technician (CMT) administered another resident's Novolog insulin to a resident who did not have a physician's order for insulin. The error occurred because the two residents had similar first names, were admitted around the same time, and were located across the hall from each other. The CMT, who was unfamiliar with the residents, did not properly verify the resident's last name and date of birth prior to administering the medication, relying only on the resident's verbal confirmation of their first name. The facility's policy required staff to identify residents before administering medication and to never administer medications supplied for one resident to another. The resident who received the incorrect medication was cognitively intact and had a diagnosis of diabetes managed with metformin, not insulin. After receiving 24 units of Novolog insulin, the resident's blood glucose was monitored closely, and the physician was notified. The resident reported feeling scared by the incident but did not experience any immediate adverse effects. The CMT could not recall the specific reason for the error but acknowledged not following proper identification procedures.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Medication Error: Fentanyl Patch Administered to Incorrect Resident
Penalty
Summary
Facility staff failed to ensure that a resident remained free from significant medication errors when a nurse administered another resident's Fentanyl patch to the wrong individual. The error occurred when the nurse, who was not accustomed to working the day shift, attempted to keep up with the pace and mistakenly applied the Fentanyl patch intended for a different resident. The nurse did not locate the existing patch and assumed it may have fallen off, leading to the incorrect administration. The error was discovered approximately 30 minutes later during charting, at which point the nurse realized the mistake. The affected resident was cognitively intact, had a diagnosis of congestive heart failure, and was on a scheduled pain regimen that did not include Fentanyl. The resident's care plan indicated the use of acetaminophen for pain management, and there was no physician's order for a Fentanyl patch. Facility policies required staff to verify medications and resident identity multiple times before administration, but these procedures were not followed, resulting in the medication error.
Inadequate Training and Sanitation Procedures in Kitchen
Penalty
Summary
Facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Specifically, staff did not provide effective training related to kitchen ware washing and sanitation. Observations showed that the dishwashing machine was consistently operating below the required minimum temperature of 120 degrees Fahrenheit, with temperatures recorded as low as 110 degrees Fahrenheit. Interviews with dietary aides and cooks revealed that they were unaware of the correct temperature requirements for the dishwashing machine, and training on this aspect was either insufficient or non-existent. The dietary manager also failed to document training or maintain competency records for kitchen staff. Additionally, the facility staff did not follow proper procedures for sanitizing kitchenware using the three-compartment sink. Observations showed that items were not soaked in the sanitizer solution for the required two minutes. Instead, items were either dipped briefly or not sanitized at all. Interviews with kitchen staff indicated a lack of proper training on the use of the three-compartment sink, with some staff members stating they had never received training or in-services on the correct procedures. The dietary manager admitted to conducting informal, undocumented verbal reviews with new staff, which did not follow a structured schedule. The facility's failure to ensure proper training and adherence to sanitation procedures in the kitchen posed a risk to the safety and effectiveness of the food and nutrition services. The lack of documented training and competency assessments further exacerbated the issue, as there was no way to verify that staff were adequately prepared to perform their duties. The administrator acknowledged that the dietary manager was responsible for kitchen staff competency but did not provide specific details on how this was monitored or enforced.
Improper Food Thawing, Storage, and Dish Drying Procedures
Penalty
Summary
Facility staff failed to thaw frozen food in a manner to prevent potential contamination. Observations showed that large tubes of ground meat were submerged in standing water at 108 degrees F, which is above the recommended temperature for safe thawing. The meat was later placed on the prep counter at room temperature before being cooked. Interviews with the cook and dietary manager (DM) revealed a lack of understanding and adherence to proper thawing procedures, with the DM acknowledging that meat should not be thawed in warm standing water or in the sanitizer sink. The facility also failed to store frozen food at safe temperatures. Observations of the reach-in freezer showed internal temperatures ranging from 8 degrees F to 24 degrees F, which is above the recommended temperature of zero degrees F or less. The freezer contained items like bread sticks that were soft to firm pressure, indicating they were not properly frozen. Interviews with staff revealed confusion about who was responsible for monitoring and recording freezer temperatures, and the DM admitted that the temperature logs did not include the reach-in freezer. Additionally, the facility failed to allow cleansed dishes to air-dry prior to stacking them in storage. Observations showed multiple instances of wet pans being stacked on metal storage shelves, some of which contained dried food debris. Interviews with kitchen staff indicated a lack of training and awareness about the importance of air-drying kitchen items. The DM confirmed that kitchen items should air-dry and should not be put away wet, but staff were not following this procedure.
Failure to Perform Timely Background Checks and EDL Checks
Penalty
Summary
The facility staff failed to perform Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks in accordance with their policy for six out of ten sampled staff members. The policy mandates that all applicants must have a CBC submitted at least two days prior to the date of hire and that no applicant may be offered a position before checking the State EDL. However, the review of personnel records showed significant delays in performing these checks. For instance, LPN M was hired on 6/9/2023, but the CBC results were received 21 days after hire, and the EDL check was performed 20 days after hire. Similar delays were observed for other staff members, with some CBC results being received as late as 329 days after hire and EDL checks being performed up to 63 days after hire. During interviews, the Human Resources Manager acknowledged the missing documentation and admitted that the policy had not been followed. The Corporate Administrator and the facility administrator both expressed expectations that staff should follow the policy, but it was evident that these expectations were not met. The facility census at the time was 87, indicating a significant oversight in ensuring the safety and compliance of the staff employed at the facility.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
Facility staff failed to notify the Ombudsman of resident transfers to the hospital for five residents out of 22 sampled. The facility census was 87. The medical records for these residents did not contain documentation of staff notification to the Ombudsman for multiple hospital transfers. Specifically, Resident #4 was transferred for pneumonia, Resident #47 had multiple transfers, Resident #61 had two transfers, Resident #77 was transferred for a fracture and a head injury, and Resident #84 was transferred for changes in mental status and aggressive behavior. The facility's monthly resident transfer log also lacked documentation of these notifications for the specified dates. Interviews with facility staff revealed a lack of clarity and responsibility regarding the notification process. The Director of Nursing was unsure who was responsible for the notifications, the Social Service Director believed the requirement was for monthly notifications, and the Registered Nurse was also unsure of the responsible party. The administrator confirmed that the Social Service Director was responsible for the notifications but acknowledged that the notifications should be given with each resident discharge or transfer. The facility did not provide a policy for Ombudsman notification of resident transfers to the hospital.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
Facility staff failed to provide written information to residents and/or their responsible parties regarding the bed hold policy at the time of transfer to the hospital. This deficiency was observed in eight residents out of a sample of 22, with the facility census being 87. The facility's policy stated that a copy of the bed hold policy should be sent with the resident upon transfer to the hospital, but this was not consistently done, and no signed bed hold agreements were found in the medical records of the affected residents. For Resident #2, the medical record showed multiple transfers to the hospital and returns to the facility without any documentation of a bed hold agreement. Similarly, Resident #4's records indicated a transfer to acute care for pneumonia and a subsequent readmission without documentation of the bed hold policy being communicated. Resident #47, assessed with moderate cognitive impairment, had multiple hospital transfers and returns without any bed hold policy documentation. Resident #61, with severe cognitive impairment, also had multiple transfers without the required documentation. Other residents, including Resident #76, Resident #77, Resident #84, and Resident #340, experienced similar issues with hospital transfers and returns without proper documentation of the bed hold policy. Interviews with facility staff, including the Social Service Director, Director of Nursing, and the administrator, revealed confusion and lack of clarity regarding who was responsible for ensuring the bed hold policy was communicated and documented. The corporate administrator confirmed that the facility should have signed copies of the bed hold agreements but was unsure why this was not being done.
Failure to Document Insulin Dosages
Penalty
Summary
Staff failed to maintain a professional standard of care by not documenting the dosage of insulin administered to three residents. The facility's policies on medication administration and the Eight Rights of Medication were not followed, as staff did not record the actual units of insulin given. This failure was observed in the Medication Administration Records (MAR) for Residents #2, #59, and #71, who all had orders for insulin administration due to their diabetes diagnoses. The MARs showed multiple instances where the insulin dosage was not documented, despite the administration being recorded. Resident #2 had orders for insulin lispro to be administered three times daily, with specific instructions on dosage calculation based on blood sugar levels and meal intake. However, the MAR for May 2024 showed numerous instances where the dosage was not documented. Similarly, Resident #59 had orders for both insulin lispro and insulin glargine, but the MAR lacked documentation of the dosages administered on multiple occasions. Resident #71 also had orders for insulin lispro, with the MAR showing 23 instances of undocumented dosages. Interviews with the Director of Nursing (DON), Certified Medication Technicians (CMTs), and Licensed Practical Nurses (LPNs) revealed that the facility's electronic medication administration system did not have a place to document the actual units of insulin given. The DON admitted that the system was not set up to record this information, and staff confirmed that they could not track the dosages administered. This lack of documentation could lead to medication errors and issues with blood sugar management, as there was no way to verify the correct amount of insulin was given to the residents.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
Facility staff failed to properly maintain the temperature of hot foods at or above 120 degrees Fahrenheit at the time of serving hall trays to six residents. Observations showed that the temperatures of various food items, such as broccoli, pork loin, and cornbread, were below the required 120 degrees Fahrenheit. Dietary Aide B did not offer to reheat the food for the residents, and multiple residents reported that their food was consistently cold. The facility's Food Service policy did not specify the expected temperature for food at the time of service, contributing to the issue. Interviews with residents and staff revealed that the problem of cold food was known but not adequately addressed. Residents who ate in their rooms frequently complained about receiving cold food, and staff members acknowledged these complaints. The Dietary Manager admitted to receiving complaints about cold food and mentioned that morning meetings to address such concerns had not been held that week. Additionally, the Dietary Manager and other staff members had inconsistent understandings of the required food holding temperatures, indicating a lack of proper training and communication. Further observations in the main dining room showed that food on the steam table was not maintained at the correct temperatures, with items like beef stroganoff and green beans being served at temperatures just above 120 degrees Fahrenheit. Interviews with kitchen staff revealed a lack of knowledge about proper food holding temperatures and inadequate training. The Dietary Manager confirmed that new cooks were trained by other kitchen staff without documented training procedures. The administrator also demonstrated a lack of awareness regarding the required food holding temperatures, indicating systemic issues in the facility's food service management.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #27, who was cognitively intact and dependent on staff for transfers, experienced falls from bed on two occasions. Despite the implementation of new interventions such as bilateral floor mats, these were not consistently in place as observed on multiple occasions. Additionally, the resident's care plan did not include directions for the use of a trapeze, mechanical lift transfer, or fall interventions, and there was a lack of documentation regarding the refusal of fall mats by the resident and family member. Resident #47, who had moderate cognitive impairment and was dependent on staff for activities of daily living and transfers, was observed multiple times in a wheelchair with a mechanical lift pad under them. However, the resident's care plan did not contain directions for the use of a low air loss mattress or mechanical lift, which were part of their physician's orders. This indicates a failure to update the care plan to reflect the resident's current needs and equipment. Resident #61, who had severe cognitive impairment and a diagnosis of a seizure disorder, had physician's orders for seizure medications and emergency interventions. Despite this, the resident's care plan did not contain directions for managing seizures or convulsions. Interviews with staff revealed that not all CNAs had access to care plans, and there was a lack of communication and training regarding the updating and accessibility of care plans. The Care Plan Coordinator (CPC) was responsible for updating care plans but lacked formal training and relied on verbal communication from nursing staff for updates, leading to inconsistencies and omissions in the care plans.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rolla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Pointe | 0.9 mi | ★★★★★ | 0 | 0 |
| Phelps Health | 1.5 mi | ★★★★★ | 0 | 0 |
| Rolla Presbyterian Manor | 1.8 mi | ★★★★★ | 0 | 0 |
| Aurora Health And Rehabilitation | 2.2 mi | ★★★★★ | 10 | 0 |
| St James Living Center | 9.4 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.