Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Reasonably accommodate the needs and preferences of each resident.

Based on observation, and interview the facility staff failed to provide reasonable
accommodations of individual needs by failing to ensure the dining room tables encouraged
meal independence for five residents (Residents #30, #63, #81, #82, and #137). The
facility census was 90.
1. Observation on 3/13/19, at 11:36 A.M., showed Resident #30 at the dining room table.
Additional observation showed the resident sat away from the table, and leaned forward to
load his/her fork. Further observation showed the resident’s leg rests on his/her
wheelchair against the pedestal of the table.
During an interview on 3/13/19, at 11:45 A.M., the resident said he/she has a hard time
reaching items on the table, because his/her chair cannot get closer to the table.
2. Observation on 3/12/19, at 1:45 A.M.-12:16 P.M., showed Resident #63 at the dining room
table. Additional observation showed the resident’s chair faced away from the table and is
unable to use his/her right arm. Further observation showed the resident’s chair at an
angle with his/her left arm is away from the table and the resident leaned forward with
each bite of food. Further observation showed the resident’s leg rest on his/her
wheelchair against the pedestal of the table.
Observation on 3/15/19, at 11:50 A.M.-12:20 P.M., showed the resident at the dining room
table. Additional observation showed the resident’s chair faced away from the table and
could not use his/her right arm. Further observation showed the resident’s chair at an
angle with his/her left arm away from the table and the resident leaned forward with each
bite of food. Further observation showed the resident’s leg rests on his/her wheelchair
against the pedestal of the table.
During an interview on 3/15/19, at 11:55 A.M., the resident said he/she can reach
everything if he/she leans forward.
3. Observation on 3/15/19, at 11:53 A.M.-12:15 P.M., showed Resident #81 at the dining
room table with his/her chair away from the table. The resident leaned forward with each
bite to load the food on his/her utensil, and then used his/her other hand to follow the
utensil to his/her mouth to catch the food he/she dropped. Further observation showed the
resident’s leg rests on his/her wheelchair against the pedestal of the table.
4. Observation on 3/12/19, at 12:20 P.M., showed resident #82 at the dining room table.
Additional observation showed the resident sat away from the table, and he/she could not
reach his/her drinks. Further observation showed the resident’s leg rests on his/her
wheelchair against the pedestal of the table.
Observation on 3/13/19, at 11:38 A.M.-12:16 P.M., showed the resident at the dining room
table with his/her dessert on his/her lap. The resident’s chair sat at an angle with
his/her left arm farthest from the table. Further observation showed the resident’s plate
remained untouched as the resident attempted to eat the strawberry cake roll on his/her
lap with his/her fingers and pinched of small amounts each time.
Observation on 3/15/19, at 11:53 A.M. until 12:15 P.M., showed the resident at the dining
room table. Additional observation showed the resident’s wheelchair was not up to the
table. The resident leaned forward to reach his/her plate with a fork and with each bite
the resident dropped food on his/her lap. After each bite the resident sat down his/her
fork to pick up the food he/she dropped on his/her lap. Further observation showed the
resident’s leg rests on his/her wheelchair against the pedestal of the table.
5. Observation on 3/15/19, at 11:45 A.M.-12:10 P.M., showed Resident #137 at the dining
room table. Additional observation showed the resident’s wheelchair was not up to the
table. The resident leaned forward reached to his/her plate with his/her fork and with

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
each bite, the resident dropped food on his/her lap.
6. During an interview on 3/15/19, at 12:06 P.M., certified nurse assistant (CNA) A said
the residents can not get close to the table because of the pedestal under the table if
they have leg rests on their wheelchairs. He/She said if there are two residents at the
table they are even further away. The CNA said there is only one table with four legs that
does not have the center pedestal.
During an interview on 3/15/19, at 12:09 P.M., licensed practical nurse (LPN) C said some
of the residents are at angle to get as close as they can to the table. He/She said the
pedestal keeps residents with foot pedals away from the table.
During an interview on 3/15/19, at 2:09 P.M., the director of nursing (DON) said the staff
try to get the residents close to the table, but the design of the tables make it
difficult.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review facility staff failed to give appropriate Center for
Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary
Notice (ABN) (CMS- ) to two resident’s (Resident #30, and #139) of three sampled residents
the facility initiated discharge from Medicare Part A Services when benefit days were not
exhausted. The facility census was 90.
1. Review of the facility’s policy Medicare Coverage Notification, dated 1/17/18, directed
the staff to provide:
-When resident’s medicare coverage is coming to an end, the social services designee will
give a 72 hour notice of non-coverage to the resident and/or responsible party;
-A Notice of Medicare Non-Coverage provided at least three days prior to discharge and
signed by resident and/or responsible party if a resident is discharging from the
facility;
-A SNF ABN is provided at least three days prior to discharge and signed by resident
and/or responsible party upon notice of non-coverage if a resident is discharging from
medicare services and remain the facility.
2. Review of Resident #30’s Skilled Nursing Facility (SNF) Beneficiary Protection
Notification Review form completed by the facility showed the facility documented:
-Medicare part A Skilled Services started 12/19/18;
-Last covered day of Part A Service 2/2/19;
-The facility/provider initiated the discharge from Medicare Part A Services when benefit
days were not exhausted;
-The resident remained in the facility;
-The SNF ABN was not provided;
-The NOMNC was given.
The resident’s record did not contain a CMS- SNF ABN letter, both the SNF ABN and NOMNC
forms are required when the resident remains in the facility.
3. Review of Resident #139’s Skilled Nursing Facility (SNF) Beneficiary Protection
Notification Review form completed by the facility showed the facility documented:
-Medicare part A Skilled Services started 9/1/18;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
-Last covered day of Part A Service 12/31/18;
-The facility/provider initiated the discharge from Medicare Part A Services when benefit
days were not exhausted;
-The resident remained in the facility;
-The SNF ABN was not provided;
-The NOMNC was given.
The resident’s record did not contain a CMS- SNF ABN letter, both the SNF ABN and NOMNC
forms are required when the resident remains in the facility.
4. During an interview on 3/13/19 at 3:00 P.M., the social service director (SSD) said
he/she gives medicare notices prior to discontinuing Medicare part A services. He/She said
he/she knows there is a SNF ABN form but he/she did not know when he/she is supposed to
issue the ABN.
During an interview on 3/15/19 at 2:13 P.M., the administrator said staff should issue the
SNF ABN and the NOMNC to residents who stay in the building.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility staff failed to complete a
significant change in status (SCSA) Minimum Data set (MDS) for three resident’s (Resident
#10, #63, and #137) with a significant change. The facility census was 90.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, directs staff
as follows:
-Comprehensive Assessments are required comprehensive assessments include the completion
of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as
care planning. Comprehensive assessments are completed upon admission, annually, and when
a significant change in a resident’s status has occurred or a significant correction to a
prior comprehensive assessment is required. They consist of:
-Admission Assessment
-Annual Assessment
-Significant Change in Status Assessment
-Significant Correction to Prior Comprehensive Assessment
-The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a
resident that must be completed when the interdisciplinary team (IDT) has determined that
a resident meets the significant change guidelines for either major improvement or
decline. It can be performed at any time after the completion of an Admission assessment,
and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s
determination was made that the resident had a significant change. A significant change is
a major decline or improvement in a resident’s status that:
-Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, the decline is not considered
self-limiting;
-Impacts more than one area of the resident’s health status; and
-Requires interdisciplinary review and/or revision of the care plan.
-Assessment Completion refers to the date that all information needed has been collected
and recorded for a particular assessment type and staff have signed and dated that the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
assessment is complete.
o A SCSA is required to be performed when a terminally ill resident enrolls in a hospice
program (Medicare-certified or State-licensed hospice provider) or changes hospice
providers and remains a resident at the nursing home. The ARD must be within 14 days from
the effective date of the hospice election (which can be the same or later than the date
of the hospice election statement, but not earlier than). A SCSA must be performed
regardless of whether an assessment was recently conducted on the resident. This is to
ensure a coordinated plan of care between the hospice and nursing home is in place.
o For required Comprehensive assessments, assessment completion is defined as completion
of the CAA process in addition to the MDS items, meaning that the registered nurse (RN)
assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item
V0200B) completion attestations. Since a Comprehensive assessment includes completion of
both the MDS and the CAA process, the assessment timing requirements for a comprehensive
assessment apply to both the completion of the MDS and the CAA process.
2. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated
assessment, dated 6/3/18, showed staff assessed the resident as:
-Severe cognitive impairment;
-Required extensive physical assistance of one staff member for locomotion, eating, and
hygiene;
-Required extensive physical assistance of two or more staff members for bed mobility,
transfers, dressing, toilet use, and bathing;
-Limited range of motion in both upper and lower extremities;
-Always incontinent of bladder;
-No weight loss;
-126 pounds (lbs.);
-No pressure ulcers present;
-No medication injections.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Dependent on staff for transfers, bed mobility, dressing, eating, hygiene, toilet use and
bathing;
-Locomotion on and off the unit did not occur;
-Limited range of motion in both lower extremities;
-Indwelling urinary catheter;
-Significant weight loss;
-122 lbs.
-Stage 4 pressure ulcer;
-Medications that required injections six out of seven days;
-Intravenous medications while a resident.
Review of the resident’s medical record showed the resident admitted to hospice services
on 9/13/18.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Dependent on staff for transfers, bed mobility, dressing, eating, hygiene, toilet use and
bathing;
-Locomotion on and off the unit did not occur;
-Limited range of motion in both lower extremities;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-Indwelling urinary catheter;
-Fall with injury;
-Significant weight loss;
-95 lbs.
-Stage 3 pressure ulcer;
-Medication that required injections every day;
-Hospice.
Staff did not complete a comprehensive SCSA MDS after the resident had decline in several
ADL’s, significant weight loss, new pressure ulcers, and the addition of hospice care.
3. Review of Resident #63’s admission MDS, dated [DATE], showed staff assessed the
resident as:
-Moderate cognitive impairment;
-Requires supervision from staff for eating;
-No impairment in range of motion;
-Occasionally incontinent of bladder, frequently incontinent of bowel;
-3 Unstageable pressure ulcers present.
Review of the resident’s admission MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Requires extensive physical assistance of one staff member for eating, and hygiene;
-Limited range of motion in one upper extremity;
-Always incontinent of bowel and bladder;
-4 Stage 3 pressure ulcers.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Requires extensive physical assistance of one staff member for eating, and hygiene;
-Limited range of motion in one upper extremity;
-Always incontinent of bowel and bladder;
-2 Stage 2 pressure ulcers.
Staff did not complete a comprehensive SCSA MDS after the resident declined in several
ADL’s, continence, new limitations in range of motion, and changes to the number and
stages of pressures.
4. During an interview on 3/15/19, on 2:52 P.M., the MDS coordinator said he/she does not
know how many or what changes require an SCSA MDS. He/She said it is required to do a SCSA
when a resident goes on or off Hospice. He/She said he/she was not the MDS coordinator
until November, and is new to the MDS process. He/She said he/she has not been to formal
MDS training.
During an interview on 3/15/19, at 3:12 P.M., the director of nursing (DON) said the MDS’s
should be completed as the RAI manual instructs.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to accurately code the Minimum
Data Set (MDS) for three resident’s (Resident #10, #30, and #63) out of 19 sampled

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
resident’s. The facility census was 90,
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, directs staff
as follows:
-Ulcer staging should be based on the ulcer’s deepest anatomic soft tissue damage that is
visible or palpable.
-Review the history of each pressure ulcer in the medical record. If the pressure ulcer
has ever been classified at a higher numerical stage than what is observed now, it should
continue to be classified at the higher numerical stage.
-Pressure ulcers do not heal in a reverse sequence, that is, the body does not replace the
types and layers of tissue (e.g., muscle, fat, and dermis) that were lost during pressure
ulcer development before they re-[MEDICATION NAME]. Stage 3 and 4 pressure ulcers fill
with granulation tissue. This replacement tissue is never as strong as the tissue that was
lost and hence is more prone to future breakdown.
4. Clinical standards do not support reverse staging or backstaging as a way to document
healing, as it does not accurately characterize what is occurring physiologically as the
ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing
and contracting such that it is less deep, wide, and long, the tissues that were lost
(muscle, fat, dermis) will never be replaced with the same type of tissue. Previous
standards using reverse staging or backstaging would have permitted identification of such
a pressure ulcer as a Stage 3, then a Stage 2, and so on, when it reached a depth
consistent with these stages. Clinical standards now would require that this ulcer
continue to be documented as a Stage 4 pressure ulcer until it has completely healed.
2. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated
assessment, dated 6/3/18, showed staff assessed the resident as:
-Severe cognitive impairment;
-Limited range of motion in both upper and lower extremities;
-No pressure ulcers present.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Limited range of motion in both lower extremities;
-Stage 4 pressure ulcer.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Limited range of motion in both lower extremities;
-Stage 3 pressure ulcer.
Observation on 3/13/19, at 4:34 P.M., showed the resident in his/her room. Additional
observation showed the resident with contractures of the shoulders, elbows, hands, hips,
knees, and feet.
Observation on 3/14/19, at 11:42 A.M., showed the resident in his/her room. Additional
observation showed the resident with contractures of the shoulders, elbows, hands, hips,
knees, and feet. Further observation showed the resident with a wound 3.2 centimeters (cm)
in length, 3.6 cm in width, and 0.9 cm in depth, on his/her coccyx. where is the wound?
During an interview on 3/14/19, at 11:49 A.M., licensed practical nurse (LPN) C said the
resident has contracture hands shoulders, legs, hips, and knees. He/She said the
resident’s wound is a healing stage 4 wound. He/She said the resident has had the wound
since (MONTH) or August.
3. Review of Resident #63’s admission MDS, dated [DATE], showed staff assessed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
resident as:
-Severe cognitive impairment;
-4 Stage 3 pressure ulcers.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-2 Stage 2 pressure ulcer.
During an interview on 3/14/19, at 11:49 A.M., LPN C said the resident’s current wounds
are Stage 3 wounds the resident had on admission. He/She said the wounds are improved and
are healing stage 3 wounds.
4. Review of Resident # 30’s admission MDS, dated [DATE], showed staff assessed the
resident as:
-Moderate cognitive impairment;
-Admission weight 212 pounds;
-No weight loss of 5 % or more in the last month or loss of 10% or more in the last 6
months.
Review of the resident’s admission assessment MDS, dated [DATE], showed staff assessed the
resident as:
-Moderate cognitive impairment;
-Admission weight 199 pounds;
-No weight loss of 5% or more in the last month or loss of 10% or more in the last 6
months.
Review of the resident’s weight loss documentation shows a 6.13% weight loss in less than
one month.
5. During an interview on 3/15/19, on 2:52 P.M., the MDS coordinator said he/she codes the
MDS’s according to the staffs’ documentation. He/She said he/she backstaged wounds, but
just read wounds should not be back staged. He/She said limited range motion should be
coded on the MDS, he/she is learning the resident’s and does not know which resident’s
have contractures. He/She said he/she was not the MDS coordinator until November, and is
new to the MDS process. He/She said he/she has not been to formal MDS training.
During an interview on 3/15/19, at 3:12 P.M., the director of nursing (DON) said the MDS’s
should be completed as the RAI manual instructs.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, facility staff failed to provide an
ongoing program of activities designed to meet the resident’s interest for three sampled
residents (Resident #33, #10, and #137). The facility census was 90.
1. Review of the facility’s one on one policy entitled, Policy and Procedure for Activity
Department One-on-One Program, undated, states the following:
The activity department provides a one-on-one program for our residents who are room/bed
bound, who refuse to participate in scheduled activities, who are diagnosed with
[REDACTED].
The activity department meet once a week to discuss and determine what activity is
suitable, stimulating, challenging, and appropriate for each resident. This will be

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
documented in the one-on-one activity book that is kept in the activity department. Then
these notes will be documented and should coordinate with the quarterly notes that are
kept in the residents chart on the wings. It will also be part of their care plan.
The activity director will bring a list of residents that are one-on-one to the care plan
meeting on Tuesday to adjust the list for any resident that may need to be added to the
one-on-one program. The activity director will also add any resident to the list after the
stand-up meeting every weekday morning if it is decided a resident needs to be added to
the one-on-one program.
2. Review of the (MONTH) activity calendar showed the following:
-No activity scheduled after dinner on weekdays and weekends;
-One on one activities scheduled two to four times a week at 2:30 P.M.
3. Review of the (MONTH) activity calendar showed the following:
-No activity scheduled after dinner on weekdays and weekends;
-One on One activities scheduled two to four times with no time noted.
4. Review of the (MONTH) activity calendar showed the following:
-No activity scheduled after dinner on weekends or weekdays;
-One on one activities scheduled three to four times with no time noted.
5. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated
assessment, dated 6/3/18, showed staff assessed the resident as:
-Severe cognitive impairment;
-Activity interview was not conducted;
-Required extensive physical assistance of one staff member for locomotion, eating, and
hygiene;
-Required extensive physical assistance of two or more staff members for bed mobility,
transfers, dressing, toilet use, and bathing;
-Limited range of motion in both upper and lower extremities.
-Section V triggered and staff marked addressed in care plan: [MEDICAL CONDITION],
cognitive loss/dementia, visual function, communication, psychosocial well-being, and
activities.
Review of the resident’s care plan, last updated 1/28/19, showed it did not contain
direction to the staff regarding activities.
Review of the resident’s medical record showed it did not contain a Activity Interest
assessment for (YEAR) or 2019.
Review of the resident’s Activity Record, dated 1/1/19-3/15/19, showed the resident
attended one activity on 1/8/19. The document did not show the resident attended any other
activities, or one on one activities.
Observation on 3/12/19, at 2:33 P.M., showed the resident with his/her eyes closed in
his/her bed, while the activity director conducted an activity.
Observation on 3/13/19, at 10:12 A.M., showed the resident with his/her eyes closed in
his/her bed, while the activity director conducted an activity
Observation on 3/15/19, at 2:14 P.M., showed the resident with his/her eyes closed in
his/her bed, while the activity director conducted an activity
6. Review of Resident #33’s quarterly MDS, dated [DATE], showed staff documented the
resident as:
-Severe cognitive impairment;
-Little interest in doing things nearly everyday;
-Total dependence for Activities of Daily Living;
-No documented goals.
Review of the resident’s care plan, dated 8/23/18, showed it did not address activities
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
for the resident.
Review of the resident’s Activity Record, dated 1/1/19-3/15/19, showed the resident
attended two activities on 2/14/19, and one activity on 1/8/19. Staff did not document
they conducted one on one visits.
Observation on 3/12/19, at 2:15 P.M., showed the resident asleep in his/her room, while
the activity director conducted an activity.
Observation on 3/13/19, at 9:30 A.M., showed the resident asleep in his/her room, while
the activity director conducted an activity
Observation on 3/14/19, at 10:00 A.M., showed the resident asleep in his/her room, while
the activity director conducted an activity
7. Review of Resident #137’s entry MDS, dated [DATE], showed the staff documented the
resident admitted to the facility on [DATE].
Review of the resident’s nurses notes, dated 2/25/19, showed staff documented the
resident:
-At most can say hi, yes, or no;
-medical history of [REDACTED].
-Impulsive at times and will attempt to stand up and self transfer with impaired
judgement;
-Visual impairment.
Review of the resident’s care plan, dated 2/25/19, showed it did not contain direction to
the staff regarding activities.
Review of the resident’s medical record showed it did not contain a Activity Interest and
Initial assessment.
Review of the resident’s Activity Record, dated 2/25/19-3/15/19, showed the staff
documented a one on one activity on 2/28/19. The documentation did not show the resident
attended any other activities, or one on one activities.
Observation on 3/12/19, at 2:10 P.M., showed the resident in his/her wheelchair unattended
in the hall, while the activity director conducted an activity.
Observation on 3/13/19, at 2:21 P.M., showed the resident with his/her eyes closed in
his/her bed, while the activity director conducted an activity.
Observation on 3/14/19, at 10:24 A.M., showed the resident in his/her bed, while the
activity director conducted an activity.
8. During an interview on 3/15/19, at 12:36 P.M., the activity director (AD) said he/she
has been here two months and just got an assistant a month ago. He/She said he/she just
started doing a few one on ones, but started with the ones who’s family’s do not visit.
He/She said he/she is late and has not completed Resident #137’s Activity assessment yet.
During an interview on 3/15/19, at 1:30 P.M., the Activity Director (AD) said he/she has
not been able to do any one-on-one time with the residents for a few weeks.
During an interview on 3/15/19, at 1:40 P.M., the care plan coordinator (CPC) said that
he/she did not know activities triggers on the MDS, his/her software does not pull it to
the careplan so residents do not have a plan of care for their activities.
During an interview on 3/15/19, at 2:00 P.M., the administrator (ADM) said the activity
director is new and they were short an assistant. He/She said they just set up a certified
activities director to oversee the new AD. He/She said residents should have activities
that meet each resident’s needs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to ensure
residents with limited range of motion (ROM) received appropriate treatments and services
to increase ROM and/or prevent further decrease in range of motion. Facility staff failed
to perform restorative therapy for one resident (Resident #10), of 19 sampled residents.
The facility census was 90.
Review of Resident #10’s annual MDS, a federally mandated assessment, dated 6/3/18, showed
staff assessed the resident as:
-Severe cognitive impairment;
-Requires extensive physical assistance of one staff member for locomotion, eating, and
hygiene;
-Required extensive physical assistance of two or more staff members for bed mobility,
transfers, dressing, toilet use, and bathing;
-Limited range of motion in both upper and lower extremities;
-The resident did not receive therapy or restorative nursing.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Dependent on staff for transfers, bed mobility, dressing, eating, hygiene, toilet use and
bathing;
-Locomotion on and off the unit did not occur;
-Limited range of motion in both lower extremities;
-The resident did not receive therapy or restorative nursing;
-The resident is on hospice.
Review of the resident’s care plan, last updated 12/4/18, directed the staff:
-Range of motion limited, at risk for/actual contractures;
-Decreased ROM in hips and knees;
-Assess for pain;
-Assess contracted area with decreased ROM for evidence of skin breakdown;
-Assist with ADL’s;
-Discuss with physician for pain relief;
-Turn and reposition frequently to maintain proper body alignment;
-Use devises, appliances, splints, or positioning pillows as indicated.
Observation on 3/13/19, at 4:34 P.M., showed the resident in his/her room. Additional
observation showed the resident with contractures of the shoulders, elbows, hands, hips,
knees, and feet. The resident did not have any positioning devices, appliances or splints.
Observation on 3/14/19, at 11:42 A.M., showed the resident in his/her room. Additional
observation showed the resident with contractures of the shoulders, elbows, hands, hips,
knees, and feet. The resident did not have any positioning devices, appliances or splints.
During an interview on 3/14/19, at 11:49 A.M., certified nurse assistant/restorative aide
(CNA/RA) E said the resident has not been on restorative since he/she quit walking. He/She
said the restorative aides do the range of motion for the resident’s they have plans for.
During an interview on 3/14/19, at 11:49 A.M., licensed practical nurse (LPN) C said
he/she is not on restorative because he/she’s on hospice. The LPN said the resident is
contractured hands shoulders, legs, hips, and knees.
During an interview on 3/15/19, at 12:09 P.M., licensed practical nurse (LPN) C said that
range of motion should be done on resident’s with contractures. He/She said he/she is not

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
sure if the resident’s with contractures are on a programs, or who documents that the
range of motion is completed for those resident’s.
During an interview on 3/15/19, at 2:05 P.M., the director of nursing (DON) said
restorative therapy performs range of motion. Resident #10 is not on a restorative program
to maintain or improve the resident’s range of motion. He/She did not know resident’s with
contractures or potential for contractures needed a program to prevent futher decline in
range of motion.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility staff failed to document
all the resident’s falls, notify the physician and family of falls, and implement and
evaluate new interventions after falls to prevent further injury from falls for one
resident (Resident #137). The facility also failed to provide safe mechanical transfers
for two resident’s (Resident #10 and #30) out of 19 sampled residents. The facility census
was 90.
1. Review of the facility’s policy Falls, dated 8/24/17, directs the staff to:
-Potential consequences of falls that include but not limited to: physical injuries,
,pain, increased risk of death, impaired function, fear of falling, and self-imposed
limitations on activities leading to social isolation.
-Decrease unavoidable falls and eliminate avoidable falls;
-After a fall:
-Ascertain if there were injuries and provide treatment as necessary;
-Determine what may have caused or contributed to the fall;
-Notify physician, family, and supervisor;
-Complete documentation in the resident’s chart;
-The nursing office will follow up with the review and assessment;
-The care plan office will follow up with the interventions;
-The care plan team will address the risk factors for the fall such as the resident’s
medical condition, facility environment issues, or staffing issues;
-Revise the resident’s plan of care and/or facility practices, as needed to reduce the
likelihood of another fall.
2. Review of Resident #137’s entry Minimum Data Set, dated dated [DATE], showed the staff
documented the resident admitted to the facility on [DATE].
Review of the resident’s Nurses Noted, dated 2/25/19, showed staff documented the
resident:
-At most can say hi, yes, or no;
-medical history of [REDACTED].
-Impulsive at times and will attempt to stand up and self transfer with impaired
judgement;
-Visual impairment.
Review of the resident’s Fall Risk Assessment, dated 2/25/19, showed staff assessed the
resident as a high fall risk.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
Review of the resident’s care plan, dated 2/25/19, showed staff are directed as follows:
-High risk for falls;
-Provide adequate lighting;
-Anticipate the resident’s needs and check frequently;
-Assist with ADL’s and toileting;
-Keep frequently used items within reach.
Review of the resident’s nurses notes, dated 3/1/19, showed staff documented they found
the resident on his/her back on the floor in front of his/her night stand. The
documentation did not include information about physician or family notification.
Review of the resident’s nurses notes, dated 3/3/19, showed staff documented they found
the resident on the floor in his/her doorway, and he/she did not receive an injury at this
time.
Review of the resident’s nurses notes, dated 3/5/19, showed staff documented they found
the resident face down on his/her left side outside of his/her bathroom. Staff noted the
resident with blood on his/her lip and nose, and a large hematoma forming on his/her
forehead with bruising started. The resident went via ambulance to the emergency room for
evaluation.
Review of the resident’s emergency room notes, dated 3/5/19, showed the resident was
evaluated for traumatic hematoma of forehead, and abrasion to the left knee.
Review of the resident’s nurses notes, dated 3/7/19, showed staff documented the resident
fell out of his/her chair and noted blood from his/her back and right side of his/her ear.
Staff sent the resident to the emergency room for evaluation.
Review of the resident’s emergency room notes, dated 3/7/19, showed the resident was
evaluated for a fall, facial contusion, scalp hematoma, and multiple contusions.
The resident’s chart did not contain documentation about the fall on 3/8/19.
Review of the resident’s nurses notes, dated 3/8/19, showed staff documented a discussion
and agreement with the resident’s family for the use of a helmet. The staff documented the
family requested the resident have a seat belt.
Review of the resident’s emergency room notes, dated 3/8/19, showed the resident was seen
for a fall, head injury and laceration on his/her face above the right eye brow. The
resident was seen 3 days ago , and yesterday for a fall. Have sutures removed in seven
days.
Review of the resident’s nurses notes, dated 3/9/19, showed staff documented the resident
returned to the facility with a helmet. The emergency room nurse reported the resident
received several stitches above the eye.
Review of the resident’s care plan, dated 3/15/19, showed staff documented the resident
fell six times before staff implemented interventions to address the resident’s falls.
3. Observation on 3/12/19, at 11:50 A.M., showed the resident in the dining room.
Additional observation showed the resident with a helmet and a dressing on the right side
of his/her forehead and a dark purple discoloration under each eye.
Observation on 3/12/19, at 1:33 P.M., showed the resident in his/her wheelchair in the
hall. The resident sat on the edge of his/her seat and rocked back and forth as he/she
propelled himself/herself down the hall with his/her feet.
Observation on 3/13/19, at 9:12 A.M., showed the resident up in his/her wheelchair in
his/her room.
4. During an interview on 3/15/19, at 11:36 A.M., CNA A said the resident fell from
his/her wheelchair several times, so they got him/her a helmet after he/she received
stitches. He/She said they try to check on him/her often.
During an interview on 3/15/19, at 12:09 P.M., LPN C said if a resident falls, the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
resident should be examined to check for injury. The physician is notified and gives
further instruction if needed, and the family is notified. The care plan should be updated
after each fall, and all the information should be documented in the nurses notes.
During an interview on 3/15/19, at 4:05 P.M., the director of nursing (DON) said the
charge nurse is expected to examine a resident after a fall. If the resident has an
injury, they are to call the physician for direction. She said the charge nurse is
expected to notify the family and the physician of any fall, and the care plan is updated
after the fall is reviewed. The DON said she spoke to the resident’s family about a seat
belt. He/She told the DON the resident used one at home and can release it
himself/herself.
5. Review of the facility’s Hoyer (mechanical) lift transfers policy, date unknown,
directs staff:
-Adjust bed height to low position;
-Position the chair next to the bed;
-By turning the resident side to side, slide the hoyer sling under the resident and
position properly;
-Wheel the lift into place over the resident with the base beneath the bed;
-Attach the sling to the mechanical lift with the hooks in place;
-Have the resident fold both arms across their chest, if possible;
-Lift the resident until the buttocks are clear of the bed. Make sure the resident is
aligned in the sling and is securely suspended in a sitting position with legs dangling
over the bottom of the sling;
-One staff member should guide the resident’s legs over the edge of the bed;
-Move the lift away from the bed, turn the resident so that he/she faces one staff member
while the other guides the resident’s body towards the chair;
-Open the legs of the lift, then bring the lift into position so the resident is over the
seat of the chair;
-Release the control knob slowly so that the resident will be gradually lowered into the
chair;
-Remove the hooks from the frame of the lift.
6. Review of Resident #10’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Severe cognitive impairment;
-Dependent on staff for transfers, bed mobility, dressing, eating, hygiene, toilet use and
bathing;
-Locomotion on and off the unit did not occur;
-Limited range of motion in both lower extremities;
-Fall with injury.
Observation on 3/14/19, at 11:42 A.M., showed LPN C and CNA F transferred the resident
with a hoyer lift. Additional observation showed the LPN lifted the resident in the lift
and the CNA walked to the other side of the bed while the resident hung in the air.
7. Review of Resident #30’s MDS, dated [DATE], showed staff assessed the resident as:
-Moderate cognitive impairment;
-Required two person total assistance for bed mobility, transfers, dressing, toilet use,
and personal hygiene;
-Limited range of motion in one lower extremity.
8. Observation on 3/12/19 at 12:47 P.M., showed CMT/CNA C and CMT/CNA D transfer the
resident from the wheelchair to the bed with a hoyer lift. Further observation showed
staff positioned the wheelchair approximately one foot from the bed and used the lift to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
lift the resident into the air. The resident sat suspended in the air for approximately 45
seconds while both of the staff members, each with one hand on the resident, rearranged
bed covers.
9. During an interview on 3/15/19 at 3:20 P.M., CNA E said the wheelchair should be right
next to the bed while one staff member guides the resident’s legs and the other staff
member guides the bottom/back area during a hoyer lift transfer. He/She added staff should
always have their hands on the resident during a transfer with a hoyer lift.
During an interview on 3/15/19 at 2:55 P.M., LPN B said there should not be space between
the bed and the wheelchair during a hoyer lift transfer. He/She said one staff member
should keep their hands on the resident at all times during a hoyer lift transfer.
During an interview on 3/15/19 at 3:43 P.M., the DON said the wheelchair should be as
close as possible to the bed and one staff member should guide the resident with their
hands while the other staff member is on the hoyer lift controls during a hoyer lift
transfer. He/She further said the resident should not hang freely in the air and the least
amount of time in the air the better.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to follow the
physician ordered dietary and fluid restrictions to maintain optimal health for one
resident (Resident #20) out of 19 sampled residents. The facility census was 90.
1. Review of the facility’s policy Assisted Nutrition and Hydration, dated 8/31/17, showed
it directed the staff to:
-Provide nutritional and hydration care and services to each resident, consistent with the
residents’ comprehensive assessment;
-Provide a therapeutic diet that takes into account the resident’s clinical condition and
preferences, when there is a nutritional indication;
-Off residents a therapeutic diet when there is a nutritional problem and the health care
provider orders a therapeutic diet.
2. Review of Resident #20’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 1/18/19, showed the staff documented as follows:
-Cognitively intact;
-Therapeutic diet;
-[MEDICAL TREATMENT] while a resident.
Review of the resident’s physician’s orders [REDACTED]. The resident should not receive
oranges, bananas, tomatoes or tomato products, peas or yogurt, limit milk to 8 oz one time
daily, and limit potatoes to Monday, Wednesday, and Friday for Stage 4 [MEDICAL
CONDITION].
3. During an interview on 3/14/19, at 9:58 A.M., the resident said he/she is on a renal
diet and is on [MEDICAL TREATMENT]. He/She said he/she has to look at the menu for each
day and instruct the staff what he/she cannot have. He/She said staff do not make sure
he/she does not get the items on his/her restrictions, if he/she does not tell the staff
what to do the staff serve him/her a regular diet, including potatoes, tomatoes, oranges,
and bananas. He/She said his/her phosphorus and potassium are often too high or out of
range. The resident said he/she also has to keep up with his/her fluid restriction. He/She

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
said staff fill his/her water pitcher in his/her room, and he/she gets fluids with his/her
medications five times a day, and a full glass at every meal. The resident said he/she is
not sure if he/she follows his/her 1500 cc fluid restriction because the staff do not tell
him/her how much is in each cup but he/she tries to make sure he/she drinks the same
amount each day.
During an interview on 3/15/19, at 11:34 A.M., certified nurse assistant (CNA) A said
there are not any resident’s in the facility that are on a fluid restriction. He/She said
the resident on a fluid restriction is in the hospital. He/She said he/she does not know
how much fluid the resident is supposed to have, he/she said the staff fill up the water
pitcher that has 800 cc and they document how much the resident drinks. He/She said he/she
does not know how much fluid dietary or the medication technician gives the resident,
he/she said the staff do not coordinate with dietary that he/she knows of. The CNA did not
know the resident is on a fluid restriction.
During an interview on 3/15/19, at 11:38 A.M., CNA G said he/she always works on the 200
hall. (The resident resides on the 200 hall). He/She said there are not any resident’s on
a fluid restriction on the 200 hall. He/She said if a resident is on a fluid restriction,
staff track the amount the resident drinks, he/she said there is not a document telling
staff how much fluid to serve the resident.
During an interview on 3/15/19, at 12:09 P.M., licensed practical nurse (LPN) C said staff
are expected to follow physicians orders for a fluid restriction. He/She said the charge
nurse notifies dietary if a resident is on a fluid restriction. He/She does not know if
the fluids the resident is served is coordinated or monitored. He/She said if residents
are on diet and/or fluid restrictions the staff should monitor and ensure the resident is
not served what is on the fluid restriction unless it is directly requested by the
resident.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to store and
label medication in a safe and effective manner in one of the two medication carts
sampled. The facility census was 90.
1. Review of the facility’s undated policy on medication storage and labeling, staff are
directed:
-Pharmaceutical medications will be labeled with the resident’s legal name, date of birth,
ordering physician, prescription number, date of packaging, name of medication, strength,
and clear dispensing instructions as ordered by the physician. In the case that a
medication is delivered that is not labeled correctly, staff will return unused package to
pharmacy for correction. Over the counter, insulin vials/pens and liquid medications will
be labeled immediately upon opening, with the date that package was opened. 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.
2. Observation on 3/12/19 at 11:26 P.M., showed the 200 hall medication cart contained:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
– Sixteen [MEDICATION NAME] (medication used to prevent/relieve heartburn) tablets loose
in a medication cup;
– One bottle of [MEDICATION NAME] (medication used to relieve chest pain) 0.4 milligram
(mg) without a resident’s name or prescription label;
– 2 unopened sample boxes of myrbetriq (medication used to treat overactive bladder) 50mg
(7 day supply) without a resident’s name or prescription label;
– three unopened sample boxes of [MEDICATION NAME] (medication used to treat overactive
bladder) 8 mg without a name or prescription label;
– One loose orange tablet in the middle drawer;
– One loose white oblong pill, one loose white round tablet, one 1/2 tablet that is white
and oblong, and one container of natural fiber powder with an expiration date of (MONTH)
(YEAR) in the bottom middle drawer.
3. During an interview on 3/12/19 at 11:26 P.M., licensed practical nurse (LPN) A said
he/she borrowed [MEDICATION NAME] from another medication cart because this medication
cart was out of them.
During an interview on 3/15/19 at 2:55 P.M., LPN B said all medication should be in it’s
original container and not loose in medication cart drawers. All personal medication
should be labeled with the resident’s name.
During an interview on 3/15/19 at 3:43 P.M., the DON said medication should be stored in
it’s original container and have a resident’s name and prescription label on the
container.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review, facility staff failed to serve food in
accordance with the nutritionally calculated menus to all residents. Facility staff also
failed to make menus for consistent carbohydrate (CCHO) diets readily available to staff
involved in food preparation and service. The facility census was 90.
1. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on regular diets with one slice of fresh baked bread at
the noon meal.
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed the
Cook Q and the Dietary Manger (DM) did not serve or offer the bread as directed to the
residents with regular diets.
During an interview on 03/13/19 at 11:35 A.M., the cook said he/she did not prepare the
meal and he/she did not know residents were to receive bread with their meal.
2. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on CCHO diets with the following at the noon meal:
-three ounces (oz.) of beef pot roast;
-a #16 (two oz.) scoop of mashed potatoes;
-one oz. of beef gravy;
-four oz. of harvard beets;
-one half slice of fresh baked bread;
-one half slice of red velvet cake roll.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 16)
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook
Q and the DM served the residents on CCHO diets the following:
-a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus);
-two oz. of beef gravy (one oz. more than directed by the menus);
-one slice of red velvet cake roll (twice as much than directed by the menus).
Observation also showed the cook and DM did not serve or offer the half slice of fresh
baked bread as directed by the menus.
Observation on 03/13/19 at 11:53 A.M., showed Week 3 menus available to staff in the
kitchen did not include CCHO menus with portion sizes to be served.
During an interview on 03/13/19 at 11:53 A.M., Cook Q said he/she serves the residents
with CCHO diets the regular foods and portion sizes all the time. The cook said he/she did
not know if the residents with CCHO diets should have anything different than the regular
diets because he/she did not have anything that shows what the CCHO diets should get.
3. Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed
bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal.
Observation on 03/13/19 at 12:00 P.M., showed the DM served the residents on pureed diets
four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus).
Observation also showed the DM did not serve or offer the pureed bread as directed by the
menus.
4. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were
directed to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod (young cod);
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed
Dietary Aide (DA) R and the DM served the residents on CCHO diets the following:
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake.
During an interview on 03/15/19 at 11:42 A.M., DA R said he/she had worked at the facility
for a year and, while he/she wished they did, the facility did not have anything that
shows what portion sizes to serve. The DA said there is no difference in what is served to
residents on CCHO diets unless they have a different texture need.
5. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were
directed to provide the residents on mechanical soft diets with four oz. of steamed
cabbage at the noon meal.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R
and the DM served the residents on mechanical soft diets four oz. of creamy cole slaw
instead of the steamed cabbage as directed by the menus.
6. Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were
directed to provide the residents on pureed diets with the following:
-a #10 (3.2 oz.) scoop of pureed breaded cod scrod;
-a #8 scoop of pureed macaroni and cheese;
-a #12 scoop of pureed creamy cole slaw;
-a #20 scoop of pureed bread with margarine;
-a #12 scoop of pureed frosted apple spice cake
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 17)
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the
DM served the residents on pureed diets the following:
-four oz. of pureed breaded cod scrod (more than directed by the menus);
-four oz. of pureed cole slaw (1.4 oz. more than directed by the menus);
-four oz. of applesauce.
Observation also showed the prepared pureed diets did not include pureed bread with
margarine.
7. During an interview on 03/15/19 at 12:36 P.M., the DM said staff should read the menus
prior to service and serve foods in accordance with the menus. The DM said he/she did not
review the menus before the meal service and he/she had not reviewed the menus with all
staff including DA R. The DM said he/she missed that the menus had bread to be served. The
DM said the facility had CCHO menus until they switched menu companies in (MONTH) (YEAR)
and the registered dietician (RD) noticed the CCHO diet menus missing from the menus
during his/her last visit a week ago. The DM said he/she just got the menus for the CCHO
diets on 03/11/18 and had not put them in the book yet. The DM said staff served residents
with CCHO diets the regular foods and portions while they did not have menus specific for
CCHO diets.
8. During an interview on 03/15/19 12:47 P.M., the administrator said he/she would expect
staff to prepare and serve food items in accordance with recipes and menus and staff are
trained on this requirement. The administrator said he/she would expect the RD to review
menus at each visit. The administrator also said the DM should monitor staff for the use
of recipes and menus when he/she is at the facility and then it would be the
responsibility of the head cook in the absence of the DM. The administrator said he/she
tries to visit the kitchen at least once a day at meal time, but he/she did not know there
were menus missing prior to 03/11/19 and he/she did not know the menus were not made
available to staff once received.

F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure therapeutic diets are prescribed by the attending physician and may be delegated
to a registered or licensed dietitian, to the extent allowed by State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide
therapeutic and modified diets in accordance with the nutritionally calculated menus to 16
residents (Residents #3, #4, #8, #15, #20, #27, #28, #45, #46, #48, #53, #54, #55, #56,
#84, and #92) with physician orders [REDACTED]. The facility census was 90.
1. Review of Resident #3’s physician orders [REDACTED]. Further review showed the
resident’s diet order as a mechanical soft, no added sodium, CCHO diet.
Review of the resident’s tray card showed staff are directed to provide the resident with
a regular texture CCHO diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on mechanical soft, CCHO diets with the following at the
noon meal:
-three ounces (oz.) of ground beef pot roast;
-a #16 (two oz.) scoop of mashed potatoes;
-one oz. of beef gravy;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-four oz. of harvard beets;
-one half slice of fresh baked bread;
-one half slice of red velvet cake roll.
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook
Q served the resident the following:
-three oz. of regular beef pot roast;
-a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus);
-four oz. of beef gravy (three oz. more than directed by the menus);
-one slice of red velvet cake roll (twice as much than directed by the menus).
Observation also showed the cook did not serve or offer the half slice of fresh baked
bread as directed by the menus.
During an interview on 03/13/19 at 11:10 A.M., the Cook said the ground meat was by
resident request and not a physician’s orders [REDACTED].>Review of the facility menus
dated 03/15/19 (Week 3, Friday), showed staff were directed to provide the residents on
mechanical soft, CCHO diets with the following at the noon meal:
-two oz. of ground breaded cod scrod (young cod);
-a #16 scoop of macaroni and cheese;
-four oz. of steamed cabbage;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed
Dietary Aide (DA) R served the resident the following:
-a two oz. whole piece of breaded cod scrod;
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake.
2. Review of Resident #4’s physician orders [REDACTED]. Further review showed the
resident’s diet order as pureed.
Review of the resident’s meal tray card showed staff were directed to provide the resident
with a pureed diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed
bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal.
Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the resident
four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus).
Observation also showed the DM did not serve or offer the pureed bread as directed by the
menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on pureed diets with the following:
-a #10 (3.2 oz.) scoop of pureed breaded cod scrod;
-a #8 scoop of pureed macaroni and cheese;
-a #12 scoop of pureed creamy cole slaw;
-a #20 scoop of pureed bread with margarine;
-a #12 scoop of pureed frosted apple spice cake
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the
DM served the resident the following:
-four oz. of pureed breaded cod scrod (more than directed by the menus);
-four oz. of pureed cole slaw (1.4 oz. more than directed by the menus);
-four oz. of applesauce.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
Observation also showed the DM did not include the pureed bread with margarine.
3. Review of Resident #8’S physician orders [REDACTED]. Further review showed the
resident’s diet order as pureed.
Review of the resident’s meal tray card showed staff were directed to provide the resident
with a pureed diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed
bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal.
Observation on 03/13/19 at 12:00 P.M., showed the DM served the resident four oz. of
pureed red velvet cake roll (1.4 oz. more than directed by the menus). Observation also
showed the DM did not serve or offer the pureed bread as directed by the menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on pureed diets with the following:
-a #10 (3.2 oz.) scoop of pureed breaded cod scrod;
-a #8 scoop of pureed macaroni and cheese;
-a #12 scoop of pureed creamy cole slaw;
-a #20 scoop of pureed bread with margarine;
-a #12 scoop of pureed frosted apple spice cake
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the
DM served the resident the following:
-four oz. of pureed breaded cod scrod (more than directed by the menus);
-four oz. of pureed cole slaw (1.4 oz. more than directed by the menus);
-four oz. of applesauce.
Observation also showed the prepared pureed diets did not include pureed bread with
margarine.
4. Review of Resident #15’s physician orders [REDACTED]. Further review showed the
resident’s diet order as a regular texture, CCHO diet.
Review of the resident’s meal tray card showed staff directed to provide the resident with
a CCHO diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on CCHO diets with the following at the noon meal:
-three ounces (oz.) of beef pot roast;
-a #16 (two oz.) scoop of mashed potatoes;
-one oz. of beef gravy;
-four oz. of harvard beets;
-one half slice of fresh baked bread;
-one half slice of red velvet cake roll.
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook
Q served the resident the following:
-a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus);
-four oz. of beef gravy (three oz. more than directed by the menus);
-one slice of red velvet cake roll (twice as much than directed by the menus).
Observation also showed the cook did not serve or offer the half slice of fresh baked
bread as directed by the menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod;
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R
served the resident the following:
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake.
5. Review of Resident #20’s physician orders [REDACTED]. Further review showed the
resident’s diet order as a regular texture, CCHO diet with a 1500 milliliter (ml) in 24
hours fluid restriction, no oranges/orange juice, bananas, tomatoes or tomato products,
peas and yogurt. Further review showed the resident’s physician directed staff to limit
the resident’s milk intake to eight ounces daily and limit potatoes to Mondays, Wednesdays
and Fridays.
Review of the resident’s meal tray card showed staff were directed to provide the resident
with a CCHO diet.
During an interview on 3/14/19, at 9:58 A.M., Resident #20 said he/she is on a renal diet
and is on [MEDICAL TREATMENT]. He/She said he/she has to look at the menu for each day and
instruct the staff on what he/she cannot have. The resident said the staff do not make
sure he/she does not get the items on his/her restrictions and if he/she does not tell the
staff what to do, the staff serve him/her a regular diet. The resident said his/her
phosphorus and potassium levels are often too high or out of range. The resident said
he/she also has to keep with his/her fluid restriction. He/She said the staff fill his/her
water pitcher in his/her room, gets fluids with his/her medications five times a day, and
a full glass at every meal. The resident said he/she is not sure if he/she is following
his/her 1500 ml fluid restriction because the staff do not tell him/her how much is in
each cup but he/she tries to make sure he/she drinks the same amount each day.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod;
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R
served the resident the following:
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake;
-an eight ounce glass water.
During an interview on 3/15/19, at 12:09 P.M., licensed practical nurse (LPN) C said staff
are expected to follow physicians orders for a fluid restriction. The LPN said the charge
nurse notifies dietary if a resident is on a fluid restriction and he/she does not know if
the fluids the resident is served is coordinated or monitored. The LPN said if residents
are on diet and/or fluid restrictions, the staff should monitor and ensure that the
resident is not served what is on the fluid restriction unless it is directly requested by
the resident.
6. Review of Resident #27’s physician orders [REDACTED]. Further review showed the
resident’s diet order as a regular texture, no added sodium, CCHO diet with skim milk and
yogurt at meals, half portion of pastry/pie/cake or alternate with fruit and half portion
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
of potatoes/rice/pasta when on the menu.
Review of the resident meal tray card showed staff were directed to provide the resident
with a CCHO diet with no desserts.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on CCHO diets with the following at the noon meal:
-three ounces (oz.) of beef pot roast;
-a #16 (two oz.) scoop of mashed potatoes;
-one oz. of beef gravy;
-four oz. of harvard beets;
-one half slice of fresh baked bread;
-one half slice of red velvet cake roll.
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook
Q served the resident the following:
-a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus);
-four oz. of beef gravy (three oz. more than directed by the menus);
-one slice of red velvet cake roll (twice as much than directed by the menus).
Observation also showed the cook did not serve or offer the half slice of fresh baked
bread as directed by the menus.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R
served the resident the following:
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake.
7. Review of Resident #28’s physician orders [REDACTED]. Further review showed the
resident’s diet order as a regular texture, CCHO diet.
Review of the resident’s meal tray card, showed staff were directed to to provide the
resident with a CCHO diet.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod (young cod);
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 at 11:58 A.M., showed the DM served the resident a #8 scoop of
macaroni and cheese (two ounces more than directed by the menus) and one square of frosted
apple spice cake. Observation also showed the DM did not serve or offer the half slice of
bread with margarine as directed by the menus.
8. Review of Resident #45’s physician orders [REDACTED]. Further review showed the
resident’s diet order as a regular texture, CCHO diet.
Review of the resident’s meal tray card, showed staff were directed to to provide the
resident with a CCHO diet.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod (young cod);
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
Observation on 03/15/19 at 11:54 A.M., showed the DM served the resident a #8 scoop of
macaroni and cheese (two ounces more than directed by the menus) and one square of frosted
apple spice cake. Observation also showed the DM did not serve or offer the half slice of
bread with margarine as directed by the menus.
9. Review of Resident #46’s physician orders [REDACTED].
Review of the resident’s meal tray card showed staff were directed to provide the resident
with a pureed diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on pureed diets with the following:
-a #8 scoop of pureed roast beef;
-a#20 (1.6 oz.) scoop of pureed bread;
-a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal.
Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the
resident, a #8 scoop of pureed roast beef (4 oz. less than directed by the resident’s
physician ordered diet), four oz. of pureed red velvet cake roll (1.4 oz. more than
directed by the menus). Observation also showed the DM did not serve or offer the pureed
bread as directed by the menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on pureed diets with the following:
-a #10 (3.2 oz.) scoop of pureed breaded cod scrod;
-a #8 scoop of pureed macaroni and cheese;
-a #12 scoop of pureed creamy cole slaw;
-a #20 scoop of pureed bread with margarine;
-a #12 scoop of pureed frosted apple spice cake
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the
DM served the resident the following:
-four oz. of pureed breaded cod scrod (2.4 oz. less than directed by the resident’s
physician ordered diet);
-four oz. of pureed cole slaw (1.4 oz. more than directed by the menus);
-four oz. of applesauce.
Observation also showed the DM did not include the pureed bread with margarine.
10. Review of Resident #48’s physician orders [REDACTED].
Review of the resident’s meal tray card showed staff directed to provide the resident with
a pureed diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed
bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal.
Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the resident
four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus).
Observation also showed the DM did not serve or offer the pureed bread as directed by the
menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on pureed diets with the following:
-a #10 (3.2 oz.) scoop of pureed breaded cod scrod;
-a #8 scoop of pureed macaroni and cheese;
-a #12 scoop of pureed creamy cole slaw;
-a #20 scoop of pureed bread with margarine;
-a #12 scoop of pureed frosted apple spice cake
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
DM served the resident the following:
-four oz. of pureed breaded cod scrod (more than directed by the menus);
-four oz. of pureed cole slaw (1.4 oz. more than directed by the menus);
-four oz. of applesauce.
Observation also showed the DM did not include the pureed bread with margarine.
11. Review of Resident #53’s physician orders [REDACTED]. Further review showed the
resident’s diet order as pureed.
Review of the resident’s tray card showed staff were directed to provide the resident with
a pureed diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on pureed diets with a #20 (1.6 oz.) scoop of pureed
bread and a #12 (2.6 oz. scoop) of pureed red velvet cake roll at the noon meal.
Observation on 03/13/19 at 12:00 P.M., showed the Dietary Manager (DM) served the resident
four oz. of pureed red velvet cake roll (1.4 oz. more than directed by the menus).
Observation also showed the DM did not serve or offer the pureed bread as directed by the
menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on pureed diets with the following:
-a #10 (3.2 oz.) scoop of pureed breaded cod scrod;
-a #8 scoop of pureed macaroni and cheese;
-a #12 scoop of pureed creamy cole slaw;
-a #20 scoop of pureed bread with margarine;
-a #12 scoop of pureed frosted apple spice cake
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed the
DM served the resident the following:
-four oz. of pureed breaded cod scrod (more than directed by the menus);
-four oz. of pureed cole slaw (1.4 oz. more than directed by the menus);
-four oz. of applesauce.
Observation also showed the DM did not include the pureed bread with margarine.
12. Review of Resident #54’s physician orders [REDACTED].
Review of the resident’s meal tray card, showed staff were directed to to provide the
resident with a CCHO diet.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod (young cod);
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 at 12:12 P.M., showed the DM served the resident a #8 scoop of
macaroni and cheese (two ounces more than directed by the menus) and one square of frosted
apple spice cake. Observation also showed the DM did not serve or offer the half slice of
bread with margarine as directed by the menus.
13. Review of Resident #55’s physician orders [REDACTED].
Review of the resident’s meal tray card showed staff directed to provide the resident with
a no added sodium with mechanical meat.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on mechanical soft, CCHO diets with the following at the
noon meal:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-three ounces (oz.) of ground beef pot roast;
-a #16 (two oz.) scoop of mashed potatoes;
-one oz. of beef gravy;
-four oz. of harvard beets;
-one half slice of fresh baked bread;
-one half slice of red velvet cake roll.
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook
Q served the resident the following:
-three oz. of regular beef pot roast;
-a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus);
-four oz. of beef gravy (three oz. more than directed by the menus);
-one slice of red velvet cake roll (twice as much than directed by the menus).
Observation also showed the cook did not serve or offer the half slice of fresh baked
bread as directed by the menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on mechanical soft, CCHO diets with the following at the noon
meal:
-two oz. of ground breaded cod scrod;
-a #16 scoop of macaroni and cheese;
-four oz. of steamed cabbage;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R
served the resident the following:
-a two oz. whole piece of breaded cod scrod;
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake.
14. Review of Resident #56’s physician orders [REDACTED].
Review of the resident’s meal tray card, showed staff were directed to to provide the
resident with a CCHO diet.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod (young cod);
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 at 11:58 A.M., showed the DM served the resident a #8 scoop of
macaroni and cheese (two ounces more than directed by the menus) and one square of frosted
apple spice cake. Observation also showed the DM did not serve or offer the half slice of
bread with margarine as directed by the menus.
15. Review of Resident #84’s physician orders [REDACTED]. Further review showed the
resident’s diet order as a regular texture, no added sodium, CCHO diet with meats served
with gravy or sauce due to inability to swallow dry meats.
Review of the resident meal tray card showed staff were directed to provide the resident
with a no added sodium, CCHO diet;
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on CCHO diets with the following at the noon meal:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-three ounces (oz.) of beef pot roast;
-a #16 (two oz.) scoop of mashed potatoes;
-one oz. of beef gravy;
-four oz. of harvard beets;
-one half slice of fresh baked bread;
-one half slice of red velvet cake roll.
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook
Q served the resident the following:
-a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus);
-four oz. of beef gravy (three oz. more than directed by the menus);
-one slice of red velvet cake roll (twice as much than directed by the menus).
Observation also showed the cook did not serve or offer the half slice of fresh baked
bread as directed by the menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod;
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R
served the resident the following:
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake.
16. Review of Resident #92’S physician orders [REDACTED]. Further review showed the
resident’s diet order as a regular texture, CCHO diet.
Review of the resident’s meal tray card showed staff were directed to provide the resident
with a CCHO diet.
Review of the facility menus dated 03/13/19 (Week 3, Wednesday), showed staff were
directed to provide the residents on CCHO diets with the following at the noon meal:
-three ounces (oz.) of beef pot roast;
-a #16 (two oz.) scoop of mashed potatoes;
-one oz. of beef gravy;
-four oz. of harvard beets;
-one half slice of fresh baked bread;
-one half slice of red velvet cake roll.
Observation on 03/13/19 during the noon meal service beginning at 11:02 A.M., showed Cook
Q served the resident the following:
-a #8 (four oz.) scoop of mashed potatoes (two oz. more than directed by the menus);
-four oz. of beef gravy (three oz. more than directed by the menus);
-one slice of red velvet cake roll (twice as much than directed by the menus).
Observation also showed the cook did not serve or offer the half slice of fresh baked
bread as directed by the menus.
Review of the facility menus dated 03/15/19 (Week 3, Friday), showed staff were directed
to provide the residents on CCHO diets with the following at the noon meal:
-two oz. of breaded cod scrod;
-a #16 scoop of macaroni and cheese;
-a #8 scoop of creamy coleslaw;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-1/2 slice of bread with Margarine;
-four oz. of country spiced apples.
Observation on 03/15/19 during the noon meal service beginning at 11:30 A.M., showed DA R
served the resident the following:
-four oz. of macaroni and cheese (two oz. more than directed by the menus);
-one slice of bread with margarine (twice as much than directed by the menus);
-one square of frosted apple spice cake.
17. During an interview on 03/13/19 at 11:53 A.M., Cook Q said he/she serves the residents
with CCHO diets the regular foods and portion sizes all the time. The cook said he/she did
not know if the residents with CCHO diets should have anything different than the regular
diets because he/she did not have anything that shows what the CCHO diets should get.
18. During an interview on 03/15/19 at 11:42 A.M., DA R said he/she had worked at the
facility for a year and, while he/she wished they did, the facility did not have anything
that shows what portion sizes to serve. The DA said there is no difference in what is
served to residents on CCHO diets unless they have a different texture need.
19. During an interview on 03/15/19 at 12:36 P.M., the DM said staff should read the menus
prior to service and serve foods in accordance with the menus. The DM said he/she did not
review the menus before the meal service and he/she had not reviewed the menus with all
staff including DA R. The DM said he/she missed that the menus had bread to be served. The
DM said the facility had CCHO menus until they switched menu companies in (MONTH) (YEAR)
and the registered dietician (RD) noticed the CCHO diet menus missing from the menus
during his/her last visit a week ago. The DM said he/she just got the menus for the CCHO
diets on 03/11/18 and had not put them in the book yet. The DM said staff served residents
with CCHO diets the regular foods and portions while they did not have menus specific for
CCHO diets. The DM said nursing tells dietary how much fluid to serve residents with fluid
restrictions at meals. The DM said they only calculate fluids from beverages and do not
include any liquids from foods such as soups, ice cream and gelatin. The DM said he/she
did not know liquids from foods should be included into the total fluid amounts. The DM
said he/she did not know Resident #20 had a fluid restriction. The DM said when dietary
gets communication forms from nursing regarding diet changes, dietary staff should change
the diet order on the resident’s meal tray card to ensure the proper diet is served.
20. During an interview on 03/15/19 12:47 P.M., the administrator said he/she would expect
staff to prepare and serve food items in accordance with recipes and menus and staff are
trained on this requirement. The administrator said he/she would expect the RD to review
menus at each visit. The administrator also said the DM should monitor staff for the use
of recipes and menus when he/she is at the facility and then it would be the
responsibility of the head cook in the absence of the DM. The administrator said he/she
tries to visit the kitchen at least once a day at meal time, but he/she did not know there
were menus missing prior to 03/11/19 and he/she did not know the menus were not made
available to staff once received.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, facility staff failed to allow

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 27)
sanitized dishes to air dry prior to stacking in storage or use to prevent the growth of
food-borne pathogens. Facility staff failed to store dishes inverted or covered to prevent
the potential for physical contamination. Facility staff also failed to wash their hands
as often as necessary using approved techniques to prevent cross-contamination. The
facility census was 90.
1. Review of the Dietary Dish Storage policy dated 05/12/18, showed:
-Following cleansing of dishes, dishes are stored upright to air dry for at least eight to
10 minutes, or until completely dried, in the drying area located by the dishwasher/three
compartment sink;
-Once dishes are completely air dried, the dishes are transferred on a clean cart to the
proper clean dish storing area;
-Dishes are to be stored inverted until time of usage.
2. Observation on 03/13/19 at 10:28 A.M., showed 10 metal food preparation pans stacked
together wet on the metal storage shelves by the dry goods storage area. Further
observation showed four plastic dome plate covers stacked together wet and stored upside
down under the steamtable.
Observation on 03/13/19 at 11:07 A.M., showed Cook Q used the wet stacked plastic dome
plate covers to cover plates of food served to residents at the noon meal.
3. Observation on 03/15/19 at 9:25 A.M., showed four metal food preparation pans stacked
together wet on the metal storage shelves by the dry goods storage area. Further
observation showed Dietary Aide (DA) R brought two metal food preparation pans over from
the clean side of the dishwashing station and placed them on the metal rack. Observation
showed the pans stacked together wet when the DA placed them on the rack.
4. Observation on 03/15/19 9:30 A.M., showed 13 glass bowls, 27 glass plates, and seven
plastic dome plate covers stacked together wet on the steamtable in the upright position
uncovered.
5. Observation on 03/15/19 at 9:32 A.M., showed DA S stacked nine plastic dome plate
covers together while wet and placed them upside down on the top of a service cart on the
clean side of the dishwashing station.
6. During an interview on 03/15/19 at 10:23 A.M., the Dietary Manager (DM) said staff
should allow clean dishes to air dry for eight to 10 minutes before they are put in
storage or used. The DM said staff should not stack dishes while wet and all staff have
been trained on this requirement.
7. Observation on 03/15/19 10:08 A.M., showed DA S removed the food processor from the
clean side of the dishwashing station while wet and placed it on the base in the cook’s
station.
8. During an interview on 03/15/19 at 10:56 A.M., the administrator said dishes should be
air dried before they are put away. The administrator said staff are trained on that
requirement upon hire and at least annually. The administrator said the DM is responsible
to monitor dish washing and storage daily.
9. Observation on 03/15/19 at 11:55 A.M., showed a stack of plastic dome plate covers
stacked together wet on the countertop in the back dining room service station. Further
observation showed DM used wet stacked dome plate covers to cover plates of food served to
residents who ate in their rooms.
10. Review of the facility’s Handwashing policy dated 06/19/17, showed dietary staff shall
clean their hands and exposed portions of their arms after handling soiled equipment or
utensils and after engaging in other activities that contaminate the hands. Further review
showed the proper handwashing technique included to dry hands thoroughly from the fingers
down to the forearms and wrists with a paper towel; if available, use clean paper towel to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 28)
turn off the water.
11. Observation on 03/15/19 from 9:30 A.M. to 9:55 A.M., showed DA S washed soiled dishes
at the mechanical dishwashing station. Observation showed, without washing his/her hands,
the DA placed clean dishes, which included coffee cups, plates and bowls, onto a service
cart. Further observation showed the DA picked up three wet stacked black plastic tubs
from the floor and placed them on the bottom shelf of the service cart next to three racks
of sanitized coffee cups.
During an interview, on 03/15/19 at 9:55 A.M., the DA said he/she had worked at the
facility for three years and he/she received training on handwashing upon hire. The DA
said staff should wash their hands before washing dishes and then every 15 minutes
thereafter. The DA said staff should wash their hands after touching anything dirty and
he/she did not have a reason for not washing his/her hands before putting away the clean
dishes.
12. During an interview on 03/15/19 at 10:00 AM., the DM said staff should wash their
hands when they enter the kitchen, between tasks and after touching anything dirty. The DM
said after they wash their hands, staff should turn off the faucet with a paper towel. The
DM said all staff are trained on when and how to wash their hands three times a year.
13. Observation on 03/15/19 at 10:05 A.M., showed DA S washed his/her hands at the handing
washing sink. Observation showed the DA used his/her wet bare hands to turn off the
faucet. Further observation showed the DA washed his/her hands at the handing washing sink
a second time. Observation showed the DA used a paper towel to turn off the faucet and
then used the same paper towel to dry his/her hands.
During an interview on 03/15/19 at 10:06 A.M., the DA said staff should turn the faucet
with a paper towel and then dry hands. The DA said the purpose of turning the faucet off
with the paper towel is to avoid making hands dirty again. The DA he/she did not think
about the towel used to turn off the faucet being dirty and that he/she should not use the
same towel to dry his/her hands.
14. During an interview on 03/15/19 10:51 A.M., the administrator said staff should wash
their hands before food preparation, after touching their body or anything dirty. The
administrator said staff should wash their hands between washing dirty dishes and handling
clean dishes. The administrator said staff should dry their hands with a paper towel and
then use another paper towel to turn off the faucet. The administrator said it is not
acceptable for staff to dry their hands with the same paper towel used to turn off the
faucet. The administrator said staff are trained on handwashing upon hire, annually and
randomly during competency observations.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to change gloves
and wash hands to prevent the spread of infection during care and treatments for three
residents ( Residents #30, #46, and #63). Facility staff also failed to properly store
oxygen tubing when not in use, to reduce the risk of infection for two residents (
Resident #34 and #33 ). In addition facility staff also failed to sanitize a multiple
resident use glucometer between residents in order to prevent the spread of infection. The
facility census was 90.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
1. According to the Infection Control Guidelines for Long Term Care Facilities (Section
3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because
micro-organisms adhere to the surface of a glove easier than to the skin of your hands.
*Hand washing remains the single most effective means of preventing disease transmission;
wash hands whenever they are soiled with body substance and when each resident’s
care is completed.
2. Observation on 3/12/19 at 12:47 P.M., showed certified medication technician/certified
nurse assistant (CMT/CNA) K wipe Resident #30’s buttocks from back to front while
performing bowel movement incontinence care.
Observation on 3/12/19 at 12:55 P.M., showed CMT/CNA J wipe resident #30’s buttocks from
back to front while performing bowel movement incontinence care.
Observation on 3/12/19 at 12:57 P.M., showed CMT/CNA J perform urinary catheter care with
the same gloves he/she used to wipe resident’s buttocks when he/she performed bowel
movement incontinence care.
3. Observation on 3/12/19, at 12:48 P.M., showed CNA E and CNA F provide care to Resident
#46. Additional observation showed the resident soiled with feces. CNA E cleansed the
resident’s back perineal area, then cleansed the resident’s front perineal area with the
same soiled gloves. The CNA did not provide care in a manner to prevent the spread of
infection causing contaminants.
4. Observation on 3/12/19, at 3:55 P.M., showed nurse assistant (NA) D provide care to
Resident #63. Additional observation showed the resident soiled with feces. NA D cleansed
the resident’s back perineal area, then cleansed the resident’s front perineal area with
the same soiled gloves. The NA then touched the resident’s linens, skin, and clean
supplies with the same soiled gloves. The NA did not provide care in a manner to prevent
the spread of infection causing contaminants.
5. During an interview on 3/15/19 at 2:55 P.M., licensed practical nurse (LPN) I said
he/she expects staff to wipe resident’s buttocks from front to back when performing
incontinence care and to sanitize hands and change gloves between dirty to clean tasks.
During an interview on 3/15/19 at 3:20 P.M., CNA L said he /she should wipe resident’s
buttocks from front to back when performing incontinence care and should sanitize hands
and change gloves between dirty to clean tasks.
During an interview on 3/15/19 at 3:43 P.M., the director of nursing (DON) said he/she
expects staff to wipe resident’s buttocks from front to back when performing incontinent
care and should sanitize hands and change gloves between dirty to clean tasks.
6. Review of the facility’s Oxygen Therapy policy, undated, showed the following:
-Purpose : to provide residents that require oxygen with the safest and most effective
care.
-Procedure: Tubing, plastic clean storage bag, and humidifier bottle will be replaced
weekly and as needed.
-Place on TAR to change tubing and humidifier bottle weekly.
-Place a clean storage bag on the side of the concentrator to store oxygen tubing (nasal
cannula/mask) between use and not in use. Change clean storage bag weekly and as needed.
7. Observation on 3/12/19 at 12:11 P.M., showed Resident #34 in the dining room.
Additional observation showed the resident’s oxygen tubing did not contain a label or
date.
8. Observation on 3/12/19 at 12:32 P.M., showed Resident #33 in the dining room.
Additional observation showed the resident’s oxygen tubing did not contain a label or
date.
Observation on 3/12/19 at 12:39 P.M., of the resident ‘s room showed the resident’s oxygen
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
tubing and nasal cannula lay over the concentrator and not bagged.
Observation on 3/14/19 at 10:45 A.M., showed the tubing and cannula in the resident’s room
not bagged, lay on the concentrator and without a date on the available plastic bag.
Observation on 3/15/19 at 11:30 A.M., showed the resident’s oxygen tubing and cannula lay
on the resident’s Geri chair unbagged and undated.
9. During an interview on 3/15/19 at 11:52 A.M., CNA A said when the oxygen tubing is not
in use, it is bagged with a date on the tubing. He/She said staff change the tubing every
Sunday.
During an interview on 3/15/19 at 12:01 P.M., LPN said the oxygen tubing is bagged when
not in use and the tubing is dated.
10. Review of the facility’s policy on blood glucometer disinfecting, dated 08/08/17,
showed staff are directed as follows:
-Glucometers are cleaned before and after use on each resident;
-Wash hands for 30 seconds;
-Don gloves;
-Place a clean paper towel over work area;
-Clean glucometer thoroughly using a specified bleach wipe (Product must specify
kills[DIAGNOSES REDACTED]) for 1 full minute and discard wipe;
-Using a new wipe, wrap the glucometer in the wipe for 3 full minutes;
-Place glucometer on designated work area paper towel;
-Allow to air dry for 1 full minute;
-Remove gloves and wash hands.
11. Observation on 3/13/19 at 10:19 A.M., showed certified medical technician (CMT) M
apply hand sanitizer and gloves. Further observation showed he /she picked up the
glucometer from the top of the medication cart and wipe it with a micro-kill wipe.
Additional observation showed he/she placed the glucometer on top of the medication cart.
The CMT did not clean the glucometer as directed by the facility’s policy.
Observation on 3/13/19 at 3:28 P.M., showed CMT N apply hand sanitizer and gloves. Further
observation showed he/she removed the glucometer from a medication cart drawer. Additional
observation showed he/she wiped the glucometer with a micro-kill wipe one time then place
it on top of the medication cart. The CMT did not clean the glucometer as directed by the
facility’s policy.
Observation on 3/14/19 at 4:30 P.M., showed CMT O remove the glucometer from the top of
the medication cart then wipe it with a micro-kill wipe one time. Further observation
showed he/she then lay the glucometer back on the top of the medication cart. The CMT did
not clean the glucometer as directed by the facility’s policy.
12. During an interview on 3/13/19 at 10:19 A.M., CMT M said he/she knew he/she should
wipe the glucometer with a micro-kill wipe but did not know how long it needed to sit in a
micro-kill wipe or to let it air dry.
During an interview on 3/15/19 at 2:55 P.M., LPN I said staff are expected to wipe down
the glucometer and wrap it in a wipe for a couple of minutes and allow it to dry before
using it on another resident.
During an interview on 3/15/19 at 3:43 P.M., the DON said staff are expected to wash the
glucometer with a bleach sheet for a minute then wrap it in a new bleach sheet and let it
air dry before each use.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265851

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SILVERSTONE PLACE

STREET ADDRESS, CITY, STATE, ZIP

2735 EAGLESON DR
ROLLA, MO 65401

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some