Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Potosi Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of medication refusal was subjected to forced medication administration by a CMT and LPN. The CMT held the resident's head and pinched the nose to force the mouth open, while the LPN restrained the resident's wrists. This resulted in the resident sobbing and screaming. The incident was witnessed by a CNA, who reported it to the facility. Interviews with staff and medical personnel confirmed the actions were unacceptable.
The facility lacked a Quality Assurance and Performance Improvement (QAPI) program with necessary policies and protocols to identify and correct quality deficiencies. The QAPI binder contained an outdated plan from 2019 and lacked a current plan with protocols for performance measurement. The Administrator admitted to having no QAPI meeting agendas, monitoring documentation, or Performance Improvement Plans (PIPs), relying instead on regulations. This deficiency potentially affected all 62 residents.
The facility failed to develop and implement a QAPI plan to address quality deficiencies, potentially affecting all 62 residents. The most recent QAPI plan was from 2019, and the Administrator admitted to not having any PIPs or meeting agendas, only conducting morning stand-up meetings to address issues.
The facility did not maintain quarterly QAPI meetings with the required members, as the medical director did not attend any meetings held in November 2023, January 2024, and July 2024. The Administrator noted the medical director's busy schedule as a reason for his absence, despite expectations for his attendance.
The facility failed to ensure two nurse aides completed their training within four months of hire. One aide, hired in February, and another, hired in August, were still enrolled in training beyond the required timeframe. An aide was observed providing care without completed certification. The Administrator was aware of the issue but did not provide a policy related to the training program.
The facility was found to have improper food storage practices, with several items improperly stored, unlabeled, undated, and contaminated. Observations included solidified salt boxes, exposed marshmallows, and a mold-like substance on powdered milk. Interviews revealed a failure to adhere to the facility's policy requiring food items to be labeled, dated, and free from debris.
The facility failed to maintain proper infection control during incontinent care for two residents, with staff neglecting hand hygiene and using soiled gloves throughout care. Additionally, the facility did not ensure proper TB screening for three residents, with delays and missing documentation in the testing process.
The facility failed to maintain proper garbage disposal practices, as observed on multiple occasions where dumpster lids were not closed and trash bags were overflowing. The Administrator acknowledged the expectation for dumpster lids to be closed and trash contained within.
Resident Subjected to Forced Medication Administration
Penalty
Summary
The facility failed to protect a resident from physical abuse during medication administration. The incident involved a resident with severe cognitive impairment, anxiety disorder, dementia with severe agitation, and severe major depressive disorder with psychotic features. The resident had a history of refusing medications. On the day of the incident, a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN) forcibly administered medication to the resident by holding the resident's head and pinching the nose until the mouth opened, while the LPN held the resident's wrists. This resulted in the resident sobbing and screaming. The incident was reported by a Certified Nurse Aide (CNA) who witnessed the event. The CNA observed the CMT pushing the resident's head and pinching the nose, while the LPN restrained the resident's wrists. The CMT then forced the medication mixed with yogurt into the resident's mouth. The CNA reported that the resident stumbled into them, sobbing and covered in yogurt, and was told by the CMT to ignore what they had seen. Interviews with the involved staff revealed that the CMT was overwhelmed and acknowledged the inappropriate method of medication administration, while the LPN admitted to being caught off guard and afraid to report the incident due to being new at the facility. Interviews with the facility's Quality Assurance Nurse Consultant, Administrator, Nurse Practitioner, and Medical Doctor confirmed that the actions taken by the staff were unacceptable. They emphasized that residents should never be forced to take medications and that staff should attempt to calm and redirect residents who refuse medications. The facility's policy on abuse prohibition was reviewed, but there was no specific policy provided for handling medication refusals by combative residents.
Lack of QAPI Program and Policies
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) program with the necessary policies and protocols to identify and correct quality deficiencies. The facility's QAPI binder contained an outdated QAPI Plan from 2019 and a template for creating a QAPI plan, but lacked a current plan with policies and protocols for identifying and correcting deficiencies, tracking and measuring performance, and establishing goals and thresholds for performance measurement. During an interview, the Administrator admitted to having no QAPI agendas for meetings, no documentation of monitoring issues, and no Performance Improvement Plans (PIPs) in place. The Administrator attempted to address issues during morning meetings but acknowledged the absence of a formal QAPI policy, relying instead on regulations. This deficiency had the potential to affect all 62 residents in the facility.
Lack of QAPI Plan and Implementation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This deficiency had the potential to affect all 62 residents in the facility. The facility did not provide a current QAPI plan or policy, and the most recent QAPI plan available was dated 2019. During interviews, the Administrator admitted to not having any Performance Improvement Projects (PIPs) in place and only conducting morning stand-up meetings to address issues as they arise. Additionally, the Administrator acknowledged the absence of QAPI agendas for meetings, with only sign-in sheets available, and recognized the need for a structured QAPI program.
Failure to Maintain Required QAPI Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's census was 62, and they did not provide a QAPI policy. A review of the QAPI meeting sign-in sheets showed that meetings were held in November 2023, January 2024, and July 2024, but the medical director did not attend any of these meetings. During an interview, the Administrator mentioned that the medical director is difficult to reach and often too busy to attend the 30-minute meetings, although she expects meetings to be held quarterly and for the medical director to attend.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that two nurse aides completed a nurse aide training program within four months of their employment, as required. Nurse Aide A was hired on 02/02/24 and was still enrolled in the training class beyond the four-month period. Similarly, Nurse Aide E, hired on 08/15/23, was also still enrolled in the training class past the four-month deadline. During an observation, Nurse Aide A was seen providing incontinent care to a resident, indicating active duty without completed certification. The facility did not provide a policy related to the nurse aide training program, and the Administrator acknowledged awareness of the issue, stating that there was a plan for the aides to get certified.
Improper Food Storage Practices
Penalty
Summary
The facility failed to store food under sanitary conditions, as observed during a survey. Several food items were improperly stored, including four unopened wrinkled boxes of salt that had become solid with a grainy substance on the outside, a potato chip laying on the shelf next to the salt boxes, and a package of opened marshmallows exposed to air. Additionally, there was an opened, undated gallon of pancake syrup with about one inch remaining, an unopened gallon jug of vinegar with black debris, and two unopened and undated containers of scalloped potatoes. Other items included an opened, undated five-pound container of peanut butter with residue on the lid, two unlabeled and undated 35-quart containers of dry cereal, and a container of powdered milk with water, debris, and a mold-like substance on the lid. Interviews with the Dietary Manager and the Administrator revealed that the facility's policy required food items to be labeled, dated, and free from debris. The Dietary Manager stated that shipments are labeled with the date upon receipt, and refrigerated items are used within three days. However, the observations indicated a failure to adhere to these policies, as many items were found unlabeled, undated, and contaminated. The Administrator confirmed the expectation for food items to be properly labeled and maintained, highlighting a discrepancy between the facility's policies and the actual practices observed.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinent care for two residents. In one instance, two CNAs did not wash or sanitize their hands before beginning care for a resident. They donned gloves, assisted the resident into bed, and performed peri-care without proper hand hygiene. After completing the care, one CNA disposed of the trash without sanitizing hands immediately after removing gloves. In another instance, a CNA and a nursing assistant used the same soiled gloves throughout the entire process of cleaning a resident, including handling soiled materials and repositioning the resident, before finally washing their hands upon leaving the room. Additionally, the facility did not ensure proper tuberculosis (TB) screening for three residents. One resident's first step TB test was delayed, and the second step was refused. Another resident's second step was not completed within the recommended timeframe, necessitating a restart of the test. A third resident had no documentation of the two-step testing. The facility's administrator and QA nurse acknowledged the lapses in TB testing, noting that some tests were missed or not properly documented, requiring an audit and restart of the tests for those affected.
Improper Garbage Disposal and Dumpster Maintenance
Penalty
Summary
The facility failed to ensure that the dumpsters were closed at all times and maintained to prevent pests and contain garbage. Observations revealed that on multiple occasions, the dumpster lids were either concaved, bent, or not closed, and trash bags were overflowing. Specifically, on October 9, 2024, at 2:41 P.M., the back right lid was concaved and not covering the dumpster, while the front left lid was not closed. On October 10, 2024, at 8:17 A.M. and 1:19 P.M., the lids on both the left and right front of the dumpster were not closed, with trash bags overflowing. On October 11, 2024, at 8:37 A.M., the left front lid was not closed, and a trash bag was resting on top of the closed right lid. During an interview, the Administrator stated that she expected the dumpster lids to be closed and trash to be inside the dumpster, not on top.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Potosi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens Health And Rehab, The | 0.7 mi | ★★★★★ | 0 | 0 |
| St Joe Manor | 12.1 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Desloge | 14.1 mi | ★★★★★ | 0 | 0 |
| Belleview Valley Nursing Home | 14.4 mi | — | 14 | 1 |
| Country Meadows | 15.5 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Potosi Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.