Silverstone Place

Inspectors wroteBased on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 glucose levels fall below the healthy range. The facility census was 86. The administrator was notified on 11/20/25 of past Non-Compliance, which occurred on 8/13/25 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, monitored the resident, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 8/13/2025.1. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to report an allegation of abuse for one resident (Resident #1) out of five sampled residents, within in two hours to the administrator and the state agency (Department of Health and Senior Services). The facility census was 65.1. Review of the facility's Abuse policy, dated 01/10/2024, showed time period to report allegations of abuse and neglect establishes two-time limits for the reporting of reasonable suspicion of a crime, depending on the seriousness.-Serious Bodily Injury-two-hour limit: If the events first cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than two hours after forming the suspicion.-All others-Within 24 hours: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to preform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to wash, rinse and sanitize mechanically washed dishes in a manner to prevent cross-contamination and allow cleansed dishes to air dry before they were stacked in storage or used to prevent the growth of foodborne pathogens. These failures have the potential to affect all residents. The facility census was 77. 1. Review of the facility's policy titled Hand Washing, dated 03/21/18, showed the policy directed staff to wash their hands whenever visibly soiled and before, during and after food preparations. [...]

Inspectors wroteBased on interview and record review facility staff failed to ensure one resident (Resident #1) remained free from significant medication errors when staff administered Resident #2's Fentanyl (an copied drug used in the treatment of severe pain) patch to Resident #1. The facility census was 85. The administrator was notified on 3/12/25 of past Non-Compliance, which occurred on 2/27/25 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 3/10/25. 1. Review of the facility's Medication administration general guidelines policy, undated, showed staff are to verify medication is correct three times before administering the medication. [...]

Inspectors wroteBased on observation, interview, and record review, 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. Facility staff failed to provide effective training to dietary staff related to kitchen ware washing/sanitation. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed dishwashing machines use either heat or chemical sanitization methods. Manufacturer's instructions must always be followed. Review of the manufacturer's label which was affixed to the front of the dish machine showed wash and rinse temperatures 120 degrees Fahrenheit (F), minimum. Review of the low temperature dish machine operation guidelines, which were mounted on the wall on the clean side of the dish machine showed: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to thaw frozen food in a manner to prevent potential contamination. Facility staff failed to store frozen food in a manner to prevent potential contamination. Facility staff failed to allow cleansed dishes to air-dry prior to stacking in storage to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed thawing some foods at room temperature may not be acceptable because it may be within the danger zone for rapid bacterial proliferation. Recommended methods to safely thaw frozen foods include: -Thawing in the refrigerator, in a drip proof container, and in a manner that prevents cross-contamination; [...]

Inspectors wroteBased on interview and record review, facility staff failed to perform Criminal Background Checks (CBC), and Employee Disqualification List (EDL) checks in accordance with facility policy for six (Licensed Practical Nurse (LPN) M, Nursing Assistant (NA) N, Certified Nursing Assistant Technicain (CMT) O, Laundry Aid U, Dietary Aid R, Dietarty Aid T) out of ten sampled staff. The facility census was 87. 1. Review of the facility CBC policy, undated, showed: -All applicants for employment must have a CBC submitted a minimum of two days prior to date of hire, -All offers of employment are contingent on a satisfactory report, -No applicant may be offered a position prior to checking the State EDL. 2. Review of LPN M's personnel record showed a hire date of 6/9/2023. Review showed the facility requested and received the CBC results on 6/30/2023 (21 days after hire). [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for five residents (Resident #4, #47, #61, #77 and #84) of 22 sampled. The facility census was 87. The facility did not provide a policy for Ombudsman notification of resident transfers to the hospital. 1. Review of Resident #4's medical record showed the resident transferred to acute care for pneumonia on 04/12/24. The record did not contain documentation staff notified the Ombudsman of the resident's transfer and readmitted on [DATE]. 2. Review of Resident #47's medical record showed the resident: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide written information to resident's and/or the responsible party of the bed hold policy at the time of transfer to the hospital on eight residents (Resident #2, #4, #47, #61, #76, #77, #84, and #340) out of 22 sampled residents. The facility census was 87. 1. Review of the facility's policy titled Hospital Transfer and Bed Hold Policy, undated, showed if the physician orders his/her patient to be transferred to the hospital, the family or responsible part will be notified and arrangements made. In the event a resident is transferred to a hospital, a copy of the policy with be sent with them. 2. Review of Resident #2's Discharge/Return Anticipated Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/24, showed the resident discharged to the hospital. [...]

Inspectors wroteBased on observation, interviews and record review, staff failed to maintain a professional standard of care, when facility staff failed to document the dosage of insulin administered to three residents (Resident #2, #59 and #71) of 22 sampled residents. The facility census was 87. 1. Review of the facility's Eight Rights of Medication policy, dated 05/2023, showed staff are instructed to ensure when staff administer medications: -Right individual; -Right medication; -Right dosage; -Right route; -Right time; -Right documentation; -Right reason; -Right to refuse. 2. Review of the facility's Medication Administration policy, undated, showed staff should ensure the correct medication doses administered to the resident. 3. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/24, showed staff assessed the resident as follows: [...]

Inspectors wroteBased on observation and interview, facility staff failed to properly maintain the temperature of hot foods at or above 120 degrees Fahrenheit (ºF) at the time staff served hall trays to six residents (Residents #13, #45, #75, #59, #42 and #77) of 22 sampled residents. Facility staff failed to maintain hold temperatures of 135 ºF, while on the steam table, during food service. Failure to maintain hold temperatures on steam table has the potential to affect all residents served in the main dining room. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed: -Avoid holding foods in danger zone temperatures which are between 41 ºF and 135 ºF; -Cooking Fresh, Frozen, or canned fruits and vegetables to a hot holding temperature of 135ºF prevents the growth of pathogenic bacteria that may be present in, or on these foods; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for three residents (Resident #27, #47, and #61) out of 22 sampled residents. The facility census was 87. 1. Review of the facility's policy titled Care Planning Policy and Procedure, revised 01/17/18, directed staff to: -Ensure the resident and family participate in the resident's care quarterly and annually to ensure there is continuity of care; -Care plan will be developed upon admission, updated quarterly, annually, with any significant change, and in accordance with the individual's needs; -Care plan will be updated as needed. Review of the facility's policy titled Falls, revised 10/05/23, directed staff to: -Care plans with individualized interventions post fall; [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to protect, label, and date stored food to prevent cross contamination and outdated use; to ensure the ice machine drained through an air gap; and to perform hand hygiene as often as necessary. Facility staff also failed to test the sanitizing solution according to facility policy and to protect stored dishes, silverware, and plastic ware to prevent contamination. This failure had the potential to affect all facility occupants. The census was 82. 1. Review of the facility's Purchasing and Storage: Facility and Resident Food and Supplies policy, undated, showed the policy did not address the storage of food in the kitchen. Observation on 3/5/23 at 10:05 A.M., of the refrigerator in the kitchenette of the main dining room, showed: - Open package of cream cheese in a zipper storage bag, undated; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain a clean blood glucose meter (device used to obtain a blood sugar reading) between two residents (Resident #49 and #195) and failed to use hand hygiene, change gloves, and wiped multiple times with the same area of a wipe/gauze during perineal care and wound care in a manner to reduce the risk of infection for one resident (Resident #23). [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain resident dignity, when staff failed to cover two residents' (Resident #23 and #36) catheter drainage bags (bag that collects urine from the bladder), failed to assist one resident (Resident #39) with dressing in a timely manner resulting in the resident sitting in his/her doorway without clothing on, posted resident care data on the closet doors in view of the hallway for one resident (Resident #37), and staff used the over-head paging system to ask staff to come to the dining room to assist the feeders. The facility census was 82. 1. Review of the facility's Resident Rights policy, dated January 2017, showed: -The facility protects and promotes the rights of each resident in order to provide a dignified life; -The right to be treated with dignity and respect; [...]

Inspectors wroteBased on interview and record review, facility staff failed to keep eight residents (Residents #7, #33, #35, #46, #193, #289, #290 and #291) from going into a negative balance, which allowed the residents to spend another resident's money without written authorization. The facility also failed to obtain written authorization before donating Resident #193's funds to MO Healthnet. The facility census was 82. 1. Review of the facility's policies showed staff did not provide a policy for managing the Resident Trust Account. 2. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 2/28/23 Resident #7's account had a negative balance of $-5.91. 3. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 2/28/23 Resident #33's account had a negative balance of $-11.13. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource limit of $5,301.85 for three residents (Residents #13, #49 and #292). The census was 82. 1. Review of the facility's policies showed staff did not provide a policy covering Medicaid resource limit. 2. Review of the Resident Trust Fund Balance Reports for the period of March 2022 through February 2023 showed Resident #13 had a trust fund balance in excess of the SSI threshold on the following dates: -On 2/28/23 the balance was $5,725.55; -On 1/31/23 the balance was $5,744.30; -On 12/31/22 the balance was $5,563.00; -On 11/30/22 the balance was $5,695.72; -On 10/31/22 the balance was $5,788.10; -On 9/30/22 the balance was $5,720.81; -On 8/31/22 the balance was $5,723.31; -On 7/31/22 the balance was $5,656. [...]

Inspectors wroteBased on interview and record review the facility staff failed to maintain an approved surety bond sufficient to ensure protection of all resident funds. The facility census was 82. 1. Review of the facility's Resident Trust Surety Bond Policy, revised 4/7/17, showed: -The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the secretary to assure the security of all personal funds of residents deposited with the facility; -The facility will maintain a non-canceling escrow agreement which has been filed with and approved by the state to cover the amount of coverage needed for the trust account. Review of the Department of Health and Senior Services bond approved list showed a surety bond and escrow amounts that totaled $78,500. Review of facility's records showed trust fund security as follows: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to serve meals on plates with silverware to residents who received hall trays. The census was 82. 1. Review of the facility policies showed the facility did not have a policy regarding the use of plates and silverware for resident meals served as hall trays. Review of the resident meal tickets, showed 42 residents received their lunch meal as a hall tray. Observation on 3/5/23 at 11:30 A.M., showed dietary aide (DA) AA and DA BB prepare resident lunches for hall tray service. The DAs prepared the meals in disposable Styrofoam containers with plastic ware. The DA also provided drinks for resident lunches in disposable Styrofoam cups with plastic lids. Further observation showed the facility had forty plates and sufficient silverware and cups available for use for the hall tray service. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for six sampled residents (Residents #1, #9, #21, #58, #80, and #193). The facility census was 86. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -Entry MDS completion date no later than the 7th calendar day from the resident's entry into the facility and submitted no later than 14 days from the date of entry into the facility; -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical, and nursing needs when staff failed to address the fluid intake limitations for one resident receiving dialysis (Resident #193), failed to address the use of antipsychotic and antidepressants for one resident (Resident #8), and failed to address falls for three residents (Resident #8, #23, and #189). The facility census was 86. 1. Review of the facility's Care Planning policy dated 2022, showed: -The interdisciplinary team (IDT) is responsible for the development of an individualized comprehensive care plan for each resident; -The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/IDT which includes, but is not limited to the following: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide activity of daily living (ADL) care to meet the basic hygiene needs for six dependent residents (Resident #25, #32, #38, #45, #53, and #75). The facility census was 82. 1. Review of the facility's Showers policy, dated January 2017, showed: -The facility is to offer showers on a bi-weekly basis with requests for more frequent showers granted and addressed via the care plan; -A shower schedule will be maintained at each nurse station for each division reflecting days for each resident's shower to be completed; -Residents right to refuse showers will be respected and addressed via the plan of care; -The charge nurse will forward all completed shower sheets to the clinical nurse managers; -Clinical nurse managers will ensure a shower sheet is received for each shower; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure the resident environment remained as free of accident hazards, when facility staff failed to ensure electronic cigarettes were kept secure for two residents (Resident #41, and #53), failed to ensure hazardous chemicals were stored in a safe manner, failed to lock an unattended medication and treatment cart and failed to propel three residents (Residents #28, #20 and #12) in wheelchairs in a manner to prevent accidents. The facility census was 82. 1. Review of the facility's Smoking Policy, dated February 2021 showed: -Any resident who smokes may do so in the designated smoke area for residents; -The designated smoke area is located outside the exit door in the Activity Department for residents; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide sufficient staff to meet the needs of the residents. The facility failed to provide showers for six residents (Resident #25, #32, #38, #45, #53, and #75), failed to administer medications in a timely manner for one resident (Resident #191), and failed to ensure call lights were answered in a timely manner. The facility census was 82. 1. Review of the facility assessment tool, dated February 23, 2023, showed: -Average census of 80-85 residents; -Direct care staff needed for a 24 hour period of time: -Licensed Nurses: 3 to 8; -Certified Medication Technicians (CMT's): 3 to 6; -Certified Nurse Aides (CNA's): 8 to 14; -Resident preferences will be considered with regard to daily schedules, bathing, naps, going to bed and medication times; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain a medication error rate of less than five percent (%) when medications were given late. There were 30 opportunities with 3 errors made, for an error rate of 10%. This affected one sampled resident (Resident #191) of six sampled residents. The facility census was 86. 1. Review of the facility's Liberal Medication Policy, dated February 2020, showed: -The purpose is to provide a general guideline to ensure safe and effective administration of medications to accommodate the resident's choice of time for administration, as well as encouraging administration of medications during times when the resident is awake; -Time specific medications ordered by a physician will have specific times indicated on the Medication Administration Record (MAR). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of two medication storage carts and two of two medication storage rooms. The facility census was 82. 1. Review of the facility's Medication Storage and Labeling Policy, undated, showed staff are directed as follows: - Pharmaceutical medications will be labeled, and stored in accordance with all state of Missouri, and federal guidelines as well as all standards of clinical practice; - Expiration dates must be checked prior to administration. Expired medications are removed from area of care immediately, and disposed of according to facility medication disposal policy, per state and federal guidelines. Review of the facility's Medication Administration General Guidelines policy, dated May 2020, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 82. 1. Review of the facility's Antibiotic Stewardship policy, undated, showed: -Antibiotic Stewardship Leaders did not include the Infection Preventionist (IP); -Included a system to monitor antibiotic use included antibiotic use and resistance reports; -Establish minimum criteria for prescribing antibiotics; -Develop facility specific standards for empiric antibiotic use, based on data from the facility; -Review antibiotic appropriateness and resistance patterns on a regular basis; -Provide access to individuals with antibiotic expertise for support staff. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for four (Residents #8, #38, #40 and #193) of five sampled residents. The facility census was 82. 1. Review of the facility's Resident Pneumococcal Immunization Policy, revised 4/27/17, showed the pneumococcal vaccine will be offered to the residents of the facility. Informed consent must be obtained from the resident or responsible representative noting the benefits and complications or side effects. Review also showed the policy did not contain a timeline for pneumococcal immunization. Review of the U.S. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate care and services for one resident (Resident #23) with an indwelling urinary catheter (a drainage tube that is inserted into the urinary bladder, left in place, and is connected to a drainage bag) who had a Urinary Tract Infection (UTI), when staff failed to ensure the resident's catheter drainage bag was kept off the floor, and failed to provide catheter care in a manner to prevent the spread of infection. The facility census was 82. Review of the facility's Catheter Care, Urinary Policy, dated August 2017, showed staff are directed to: -Maintain catheter tubing coiled to gravity, ensure privacy bag intact and ensure catheter tubing does not make contact with the floor; -Provide catheter care every shift; -Identify and document clinical indications for the use of a catheter. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide oxygen as ordered by the physician and failed to ensure proper equipment maintenance for one resident (Resident #40). The facility census was 82. 1. Review of the Facility Assessment, updated 2/23/23, showed 25-31 residents per month received oxygen therapy. Oxygen therapy was included in additional competencies in ongoing educational training. Review of the facility's policies showed staff did not provide a policy for oxygen use. Review of the oxygen concentrator operator's manual showed: -This device contains an alarm system which monitors the state of the device and alerts of abnormal operation, loss of essential performance or failures; -Alarm conditions are shown on the LED display; -All alarms are low priority technical alarms. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide orders for ongoing assessment after dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), or have a system in place for ongoing assessments or communication with the dialysis clinic for two residents (Resident #17 and #193) who received dialysis. The facility also failed to include dialysis specific assessments and interventions in the residents' care plans. The facility census was 82. 1. Review of Facility assessment, dated 2/23/23, showed an average of two to seven residents on dialysis per week. Additional competencies included ongoing training in dialysis care. Review of the facility's policies showed staff did not provide a policy for on going communication and collaboration with the dialysis facility regarding dialysis care and services. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to all residents and visitors. The facility census was 86. 1. Review of the facility policies provided showed the facility did not provide a policy for the required postings. Observation of the facility from 3/5/23 at 10:00 A.M. through 3/9/23 at 12:00 P.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents or visitors to use if needed. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete or post the required nurse staffing information in an area readily accessible to residents and visitors. The facility census was 86. 1. Review of the facility's Staffing Hours Posted policy, undated showed: -Human Resources will post every day: the staff by discipline for the community; -Staffing will be broken down by Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Medication Technician (CMT) and Certified Nurse Aide (CNA); -The posting will be hung in the lobby for all visitors and residents to see; -Human Resources will update the posting for any call ins or changes to the schedule; -Human Resources will keep the old posting in their office for storage. Observation 3/5/23 at 10:00 A.M. [...]