Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 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.
The facility failed to follow physician orders for three residents. One resident with diabetes, ESRD, and vitamin deficiency missed multiple ordered meds because they were unavailable, including insulin, Vitamin B6, pain medication, and other scheduled treatments. Another resident with chronic respiratory failure did not have oxygen tubing changed as ordered, and observation found tubing dated weeks earlier. A third resident with anal cancer missed ordered fleet enemas before a rectal exam, so the procedure had to be rescheduled after staff forgot to give the prep.
Dialysis communication forms were not consistently completed or sent with two residents receiving dialysis, and daily AV fistula thrill/bruit checks were not followed for one resident. One resident with ESRD had many missed communication forms across dialysis visits and an AV access order that did not cover every day of the week, while another resident with ESRD had repeated missing or incomplete dialysis forms, including missing signatures and pre-dialysis vital signs. The DON stated staff relied on dialysis to check the access on dialysis days and did not consistently ensure the forms were completed.
Failure to complete CNA annual performance reviews. Review of three sampled CNAs’ personnel files showed no documentation of annual performance reviews, and the facility did not have a policy for CNA annual performance reviews. The DON stated performance reviews had not been done, and the Administrator said he would not necessarily expect them annually.
A facility failed to post nurse staffing data at the beginning of each shift on multiple observed days. The posted information remained dated from an earlier day and included the census plus the total number and actual hours worked per shift by licensed and unlicensed staff responsible for resident care. The DON said an LPN updates the postings and that they should be updated daily, and the Administrator and DON stated staffing should be posted daily.
Medication error rate exceeded 5% after surveyors found three errors in 33 opportunities. The DON administered insulin to one resident without priming Humalog and Lantus pens per manufacturer instructions, and to another resident gave 20 units of insulin lispro when the order was for 6 units per sliding scale. The DON and Administrator stated meds should be given as ordered and insulin pens primed per manufacturer instructions.
Items were found stored on overbed light fixtures in seven resident rooms, including stuffed animals, hats, picture frames, flowers, and other decorations. The CNA said family members often place items on the lights, while the DON and Administrator stated the fixtures should be kept free of items due to possible hazards.
Failure to Provide Required CNA In-Service Training: The facility failed to provide the required annual in-services for three CNAs, including dementia care/management, abuse/neglect prevention, and training for cognitively impaired residents and residents with special needs. Record review showed one CNA had no documented in-services, another had eight in-services with no length documented, and a third had no documented in-services; the DON and LPN stated staff should receive at least 12 in-services per year.
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.
Failure to Follow Physician Orders for Medications, Oxygen Tubing, and Procedure Prep
Penalty
Summary
The facility failed to follow physician orders for medications, oxygen tubing changes, and pre-procedure preparation for three residents. The report states that the facility did not give ordered medications to one resident, did not change oxygen tubing as ordered for another resident, and did not administer ordered enemas before a scheduled rectal exam for a third resident, which caused the procedure to be rescheduled. The facility’s policies reviewed in the report did not address following physician orders or changing oxygen equipment in a way that matched the physician orders. For one resident with diabetes mellitus, vitamin deficiency, and end stage renal disease, the record showed multiple ordered medications in place, including Lokelma, pyridoxine (Vitamin B6), scopolamine, hydrocodone-acetaminophen PRN, Lyrica, Zyrtec, Tresiba insulin, irbesartan, and lorazepam. The MAR documented repeated missed doses because medications were unavailable, including missed doses of Lokelma, Vitamin B6, scopolamine, Zyrtec, Tresiba insulin, irbesartan, lorazepam, hydrocodone-acetaminophen, and Lyrica across January, February, and March 2026. The resident stated that medicine, including insulin and pain pills, runs out and that this happens a lot. A CMT said medications should be available and noted that Vitamin B6 should have been stocked, adding that the resident would not refuse it. For another resident with chronic respiratory failure with hypoxia, the record showed an order for oxygen at two liters per minute via nasal cannula and an order to change oxygen tubing weekly. The MAR showed tubing changes on 03/01/26 and 03/08/26, but observation on 03/12/26 found the resident using oxygen tubing dated 02/22. The resident said staff does not change the tubing often and that at one point it had been almost a month, with the tubing becoming stiff. An LPN stated nurses are responsible for changing or assuring the tubing is changed and that it is normally changed on Sunday nights. For a third resident with anal cancer, constipation, and Crohn’s disease, the record showed an order for two saline fleet enemas before a rectal exam. The procedure instruction form listed the rectal exam and special instructions for the enemas, but the Social Services note documented that the resident did not get the preparation and the appointment was rescheduled. The resident said the family member drove to the appointment, but staff then said it had to be rescheduled because the enemas were forgotten, causing frustration and worry. Staff interviews confirmed the order had been entered, but the enemas were not administered because the nurse got busy and forgot.
Dialysis Communication Forms Not Completed and AV Fistula Checks Not Done Daily
Penalty
Summary
The facility failed to ensure dialysis communication forms were completed and sent with two residents on all dialysis days, and failed to follow its own policy for daily AV fistula thrill/bruit checks for one resident. The facility policy required the dialysis communication record to accompany the resident on each dialysis visit and be completed by both the facility and dialysis unit, with the returned form maintained in the medical record. It also required nurses to check AV access daily for thrill/bruit and document it daily. Resident #3 had ESRD, muscle weakness, and hyperkalemia and was ordered to receive dialysis three times weekly. Review of the dialysis communication forms from December 2025 through March 2026 showed 29 missed opportunities for completion out of 43 dialysis visits. The record also showed the resident’s orders for AV fistula thrill/bruit checks did not cover every day of the week, despite the policy requiring daily checks. The resident stated staff took vital signs before dialysis, gave medications before and after dialysis, but did not take vital signs after return and the form sometimes remained in the backpack and was reused when the dialysis schedule changed. Resident #42 had ESRD, vitamin deficiency, and shortness of breath and was also ordered for dialysis three times per week. Review of the hemodialysis communication forms from December 2025 through March 2026 showed 17 missed opportunities for completion out of 18 dialysis visits, including forms that were not completed, not signed by facility staff, or lacked pre-dialysis vital signs. The resident stated staff sometimes took vital signs before dialysis and sometimes gave the communication form, but did not consistently do anything when the resident returned from dialysis and did not always ask for the form. The DON stated the current order for Resident #3 needed correction to include Monday, and also stated staff did not check the thrill/bruit on dialysis days because it was done at dialysis.
Failure to Complete CNA Annual Performance Reviews
Penalty
Summary
The facility failed to ensure three of three sampled CNAs received an annual performance review. Review of the personnel files for CNA D, CNA E, and CNA F showed hire dates of 10/30/24, 10/04/24, and 07/18/24, respectively, and none of the files contained documentation of an annual performance review. The facility also did not provide a policy regarding CNA annual performance reviews. During interview, the DON stated the prior Administrator did not do performance reviews and that they had not been doing them. The Administrator stated he would not necessarily expect performance reviews to be completed annually and said the facility does not have a policy, noting they follow the regulations.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post the nurse staffing data at the beginning of each shift for three of four observed days, with the census at 52. Observation and record review showed the posted nurse staffing data on 03/11/26 at 10:15 A.M., 03/12/26 at 12:00 P.M., and 03/13/26 at 9:00 A.M. were all dated 03/10/26 and included the census, total number, and actual hours worked per shift by licensed and unlicensed staff responsible for resident care. The facility did not provide a policy regarding daily staffing data postings. During interview, the DON stated that LPN G updates the staffing postings and that they should be updated daily. The Administrator and DON later stated they would expect staffing to be posted daily.
Medication Error Rate Exceeded Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less. Surveyors identified 33 medication administration opportunities and three errors, resulting in an error rate of 9.09%. The deficiency affected two sampled residents, and the facility census was 52. The facility’s insulin pen checklist required staff to prime the pen before administration, and the manufacturer’s instructions for both Humalog and Lantus insulin pens required priming or a safety test before giving the dose. For one resident, the DON administered Humalog insulin and Lantus insulin without priming either pen with two units before giving the ordered doses. The resident had physician orders for Humalog KwikPen insulin before meals and at bedtime, including a sliding-scale order and a fixed 15-unit dose, as well as Lantus 52 units twice daily. During observation, the DON obtained the resident’s FSBS, selected the ordered dose on each pen, and administered the insulin without completing the required priming step. For a second resident, the DON obtained the FSBS, primed the insulin pen, and then administered 20 units of insulin lispro when the physician’s order called for 6 units per sliding scale. The DON immediately called the physician after the error and documented the event in a progress note. During interviews, the DON stated insulin pens should typically be primed with two units, though one type requires three units, and the Administrator and DON stated medications should be given as ordered, insulin pens should be primed per manufacturer instructions, and the medication error rate should be less than 5%.
Items Stored on Overbed Light Fixtures
Penalty
Summary
The facility failed to provide a safe and functional environment by allowing items to be stored on top of overbed light fixtures in seven resident rooms. Surveyors observed multiple items placed on the light fixtures, including stuffed animals, hats, picture frames, small flower decorations, canvas pictures, flowers, a horse picture, a piece of paper with a drawing, and crocheted plant decorations. The facility census was 52, and the report stated that the deficient practice had the potential to affect all residents and staff in the facility. The facility did not provide a policy regarding overbed light safety. During interview, a CNA stated he/she does not put things on top of the lights in resident rooms, but family members often place pictures and items on them. The DON stated items should not be placed on the light fixtures due to possible hazards, and the Administrator and DON later stated they would expect overbed light fixtures to be free from items due to possible hazards.
Failure to Provide Required CNA In-Service Training
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-services for three CNAs, including training in dementia management, abuse/neglect prevention, areas of personal weakness, areas of concern based on the facility assessment, the care of cognitively impaired residents, and the care of residents with special needs. The deficiency was identified through interview and record review and involved CNA D, CNA E, and CNA F, all three of the sampled CNAs. The facility census was 52, and the deficient practice had the potential to affect all residents. Review of CNA D's personnel file showed a hire date of 10/30/24 with no in-services recorded from 10/30/24 through 02/27/26 and no documented trainings for dementia management, abuse/neglect prevention, areas of personal weakness, the care of cognitively impaired residents, or the care of residents with special needs. CNA E's file showed a hire date of 10/04/24 and eight in-services dated from 02/24/25 through 02/27/26, but the length of each in-service was not documented and there were no documented trainings for dementia management, areas of personal weakness, the care of cognitively impaired residents, or the care of residents with special needs. CNA F's file showed a hire date of 07/18/24 with no in-services recorded from 07/18/24 through 02/27/26 and no documented trainings for dementia management, abuse/neglect prevention, areas of personal weakness, the care of cognitively impaired residents, or the care of residents with special needs. The DON stated CNA D and CNA F had no recorded in-services because they worked PRN, and the DON and LPN said staff should have at least 12 in-services per year, including resident rights, peri care, hand hygiene, privacy, and workplace violence.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 | ★★★★★ | 17 | 0 |
| Nhc Healthcare, Desloge | 14.1 mi | ★★★★★ | 0 | 0 |
| Belleview Valley Nursing Home | 14.4 mi | — | 21 | 1 |
| Country Meadows | 15.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.