Inspection Reports for
Potosi Manor
307 SOUTH HIGHWAY 21, POTOSI, MO, 63664-9317
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
62 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Oct 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident during medication administration.
Complaint Details
Complaint #MO243888 regarding physical abuse of Resident #1 during medication administration was substantiated. Immediate jeopardy was identified and corrected.
Findings
The facility failed to protect a confused and vulnerable resident from physical abuse when staff forcibly administered medication by holding the resident's hands and pinching the nose, causing distress. The facility investigated, terminated involved staff, and provided staff training on abuse and medication administration.
Deficiencies (1)
Failure to protect a resident from physical abuse during medication administration.
Report Facts
Residents present: 62
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Involved in forcibly administering medication to Resident #1 |
| LPN B | Licensed Practical Nurse | Held resident's wrists during medication administration incident |
| CNA C | Certified Nurse Aide | Witnessed and reported the abuse incident |
Inspection Report
Routine
Census: 62
Deficiencies: 7
Date: Oct 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nurse aide training, food storage and sanitation, waste disposal, quality assurance programs, infection control, and tuberculosis screening at the nursing home.
Findings
The facility was found deficient in ensuring nurse aides completed training within four months, maintaining sanitary food storage, properly closing dumpsters, implementing an effective QAPI program, adhering to infection control practices during incontinent care, and conducting timely tuberculosis screenings for residents.
Deficiencies (7)
Failed to ensure two nurse aides completed training within four months of employment.
Failed to store food under sanitary conditions, increasing risk of food-borne illness.
Failed to ensure dumpsters were closed at all times and maintained to keep pests out and garbage contained.
Failed to have a Quality Assurance and Performance Improvement (QAPI) program with policies and protocols.
Failed to ensure the QAA/QAPI committee developed and implemented appropriate corrective plans of action.
Failed to maintain quarterly QAA/QAPI committee meetings with required members including medical director.
Failed to maintain proper infection control practices during incontinent care for two residents and failed to ensure proper tuberculosis screening for three residents.
Report Facts
Facility census: 62
Number of nurse aides not completing training within 4 months: 2
QAPI meetings held: 3
Number of residents with improper TB screening: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Named in nurse aide training deficiency and infection control observation |
| NA E | Nurse Aide | Named in nurse aide training deficiency |
| CNA C | Certified Nurse Assistant | Named in infection control deficiency observation |
| CNA D | Certified Nurse Assistant | Named in infection control deficiency observation |
| CNA B | Certified Nurse Assistant | Named in infection control deficiency observation |
| Administrator | Interviewed regarding multiple deficiencies and expectations | |
| Dietary Manager | Interviewed regarding food storage policies | |
| Quality Assurance Nurse | Interviewed regarding tuberculosis screening and QAPI program |
Inspection Report
Routine
Census: 56
Deficiencies: 9
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, care, assessment, safety, staffing, and sanitation in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure dignity in catheter care, inadequate posting of Ombudsman information, failure to issue Medicare notices, untimely and inaccurate Minimum Data Set (MDS) assessments, inadequate pressure ulcer care documentation, failure to post nurse staffing data properly, unsanitary kitchen conditions, and unsafe environmental conditions such as items on light fixtures, use of wax warmers, and broken skylight windows.
Deficiencies (9)
Failed to ensure dignity of residents by not properly covering urinary catheter bags.
Failed to provide accessible information on the location of the State Long-Term Care Ombudsman program.
Failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) when Medicare covered services had ended.
Failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner.
Failed to accurately code the Minimum Data Set (MDS) for anticoagulant medication.
Failed to document weekly skin assessments and status of pressure ulcers for residents with wounds.
Failed to post nurse staffing data with all required components in a clear and readable format daily.
Failed to maintain sanitary kitchen conditions including buildup of grime and lack of cleaning schedules.
Failed to provide a safe environment by allowing items on light fixtures, use of wax warmers, and presence of broken skylight windows.
Report Facts
Residents affected: 3
Facility census: 56
Days late: 150
Days late: 156
Wound measurements: 6.5
Wound measurements: 5
Wound measurements: 3.5
Wound measurements: 3
Wound measurements: 2.1
Wound measurements: 5
Wound area: 20
Wound volume: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Interviewed regarding dignity bag use for catheter care and wound care documentation |
| CNA C | Certified Nurse Aide | Interviewed regarding dignity bag use for catheter care |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter bag dignity bags, Ombudsman postings, MDS assessments, wound care, and staffing postings |
| Activity Director | Activity Director (AD) | Interviewed regarding Ombudsman information discussion |
| Bookkeeper | Interviewed regarding SNFABN form knowledge | |
| MDS Coordinator | Interviewed regarding MDS assessments and coding | |
| LPN A | Licensed Practical Nurse | Documented wound care and interviewed about wound measurements |
| RN D | Registered Nurse | Documented wound care |
| Dietary Manager | Interviewed regarding kitchen cleaning and sanitation | |
| Administrator | Interviewed regarding Ombudsman postings, SNFABN, MDS, wound care, staffing postings, kitchen sanitation, and environmental safety | |
| CNA F | Certified Nurse Assistant | Interviewed regarding safety concerns about decorations on light fixtures |
| Housekeeper G | Interviewed regarding removal of unsafe items and reporting broken glass | |
| Maintenance Supervisor | Interviewed regarding broken skylight windows and maintenance reporting |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 3
Date: Feb 26, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, including medication monitoring, incontinent care, and drug regimen review at Potosi Manor.
Findings
The facility failed to obtain timely lab orders for Coumadin monitoring for one resident, failed to provide adequate incontinent care for two residents, and failed to ensure the pharmacy consultant identified and reported the absence of lab work related to Coumadin use. All deficiencies were noted to cause minimal harm or potential for actual harm affecting few residents.
Deficiencies (3)
Failed to obtain orders for labs related to Coumadin monitoring for one resident (Resident #17).
Failed to provide adequate incontinent care for one resident (Resident #9) and one resident (Resident #21), including improper cleaning techniques.
Failed to ensure the pharmacy consultant identified and reported the absence of lab work related to Coumadin use for one resident (Resident #17).
Report Facts
Facility census: 37
PT lab value: 15.5
INR lab value: 1.4
Coumadin dose: 4
Coumadin dose: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding PT/INR monitoring and contacting physician for new STAT order |
| CNA E | Certified Nursing Assistant | Interviewed regarding incontinent care procedures |
| Licensed Practical Nurse C | Licensed Practical Nurse | Observed providing incontinent care |
| CNA B | Certified Nursing Assistant | Observed and interviewed regarding incontinent care |
| CNA A | Certified Nursing Assistant | Observed and interviewed regarding incontinent care |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for PT/INR monitoring and incontinent care |
| Administrator | Administrator | Interviewed regarding expectations for lab orders and incontinent care |
| Pharmacist Consultant | Pharmacist Consultant | Interviewed regarding drug regimen review and failure to report lack of lab testing |
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