Potosi Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders when medication was not given as ordered for one resident (Resident #3), when oxygen tubing was not changed as ordered for one resident (Resident #5) and when medical preparation was not given prior to a scheduled examination, resulting in the procedure needing to be rescheduled for one resident (Resident #31) out of 13 sampled residents. The facility's census was 52. Review of the facility's Oxygen Equipment policy, undated, showed: - All oxygen equipment changed every seven days when heated humidification is used and monthly when unheated humidification is used; - Did not address being changed weekly per the physician orders. Review of the facility's Physician Orders policy, undated, showed it did not address following physician orders. 1. Review of Resident #3's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure communication forms that reflected ongoing coordination and collaboration between facility staff and the dialysis (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed) staff were sent with two residents (Residents #3 and #42) out of two sampled dialysis residents on all dialysis days and failed to follow their policy to ensure Resident #3's arteriovenous (AV - connection of an artery and a vein) fistula (artificial blood vessel connections between an artery and a vein ) was checked daily for the thrill (vibrating sensation)/bruit (whooshing sound). The facility's census was 52. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of the three sampled Certified Nurse Aides (CNAs) received an annual performance review. The facility's census was 52. The facility did not provide a policy regarding CNA annual performance reviews.1. Review of CNA D's personnel file showed:- Hire date of 10/30/24;- No documentation of an annual performance review.2. Review of CNA E's personnel file showed:- Hire date of 10/04/24;- No documentation of an annual performance review.3. Review of CNA F's personnel file showed:- Hire date of 07/18/24;- No documentation of an annual performance review. During an interview on 03/12/26 at 2:12 P.M., the Director of Nursing (DON) said the prior Administrator did not do performance reviews, and they haven't been doing them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing data at the beginning of each shift for three of four observed days. The facility's census was 52. The facility did not provide a policy regarding daily staffing data postings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less when staff failed to prime insulin pens before the administration of insulin and administered the incorrect amount of insulin. There were 33 opportunities with three errors made, for an error rate of 9.09%. This affected two residents (Residents #2 and #23) out of 13 sampled residents. The facility's census was 52. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment by allowing items to be stored on top of overbed light fixtures for residents in seven rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 52. The facility did not provide a policy regarding overbed light safety. Observation of resident rooms showed: - On 03/10/26 at 11:26 A.M., room [ROOM NUMBER] with multiple stuffed animals on the light fixture above the bed by the door and above the bed by the window; - On 03/10/26 at 11:38 A.M., room [ROOM NUMBER] with two hats and a stuffed animal on the light fixture above the bed by the window; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required 12 hours of in-services per year to include 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 for three Certified Nurse Aides (CNAs D, E, and F) out of three sampled CNAs. The deficient practice had the potential to affect all residents. The facility's census was 52. The facility did not provide a policy regarding nurse aide training and in-service requirements. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one confused and vulnerable resident's (Resident #1), out of four sampled residents, right to be free from physical abuse during medication administration, when facility staff held the resident's hands and forced his/her medication in his/her mouth- resulting in the resident sobbing and screaming the staff were devils. The facility census was 62. On 10/22/24 at 2:00 P.M., the Administrator was notified of the past non-compliance immediate jeopardy (IJ) which began on 10/19/24. Upon discovery, the facility immediately conducted an investigation, removed and terminated the staff involved, and inserviced staff on abuse and neglect and medication administration. The IJ was corrected on 10/21/24. Review of the facility's policy titled, Abuse Prohibition Protocol Manual, undated, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI, a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 62. The facility did not provide a policy related to the QAPI program. Review of the facility's QAPI binder showed: - The most recent QAPI Plan dated 2019; - A template showing how to create a QAPI plan; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 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 had the potential to affect all residents in the facility. The facility census was 62. The facility did not provide a QAPI plan or policy. Review of documentation provided by the Administrator showed: - A template to create a QAPI plan, but no current QAPI plan; - The most current QAPI plan dated 2019. During an interview on 10/10/24 at 3:51 P.M., the Administrator said she does not have any Performance Improvement Projects (PIPs) in place. They do have a morning stand up meeting and try to look into things that come up in those meetings. [...]

Inspectors wroteBased on interview and record review, 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. The facility did not provide a QAPI policy. Review of the QAPI meeting sign in sheets, provided by the Administrator, showed: - Meetings were held in November 2023, January 2024, and July 2024; - The medical director did not attend any of the meetings. During an interview on 10/10/24 at 3:51 P.M., the Administrator said the medical director is hard to catch when he is in the building. He is so busy that it's difficult for him to come to a 30 minute meeting. She will try to go over things with him, but he doesn't come to quarterly meetings. She would expect meetings to be held quarterly and for the medical director to come to QAPI meetings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two nurse aides (NAs) completed a nurse aide training program within four months of his/her employment at the facility. The facility's census was 62. The facility did not provide a policy related to the NA training program. 1. Review of NA A's personnel file showed: - A hire date of 02/02/24; - NA A currently enrolled in class; - The facility failed to ensure the completion of the program within four months of NA A's hire date. 2. Review of NA E's personnel file showed: - A hire date of 08/15/23; - NA E currently enrolled in class; - The facility failed to ensure the completion of the program within four months of NA E's hire date. Observation on 10/11/24 at 2:15 P.M. showed NA A provided incontinent care for Resident #36. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 62. Review of the facility's policy titled, Receiving and Storage of Food, dated May 2015, showed: - The Dining Service Manager (DSM) is responsible for receiving and storing food and non-food items; - Follow the rule of First In, First Out; - Food is stored in designated areas; - Keep all foods in clean, undamaged wrappers or packages; - Reseal open boxes effectively; - Keep storage areas clean and dry. Observation on 10/08/24 at 11:35 A.M. showed: - Four unopened wrinkled boxes of salt that had become solid with a grainy substance on the outside of the boxes; - A potato chip laying on the shelf next to the salt boxes; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices during incontinent care for two residents (Resident #8 and #36) outside of the 16 sampled residents. The facility failed to ensure proper Tuberculosis (TB-a communicable disease that affects the lungs, characterized by fever, cough and difficulty breathing) screening of three residents (Resident #19, #38 and #45) out of five sampled residents. The facility's census was 62. Review of the facility's policy titled, Handwashing, undated, showed: - Purpose to reduce transmission of organisms from resident to resident, staff to resident, and resident to staff; - Use of soap, comfortably hot water, and disposable towel; - Soap hands well and briskly rub together, paying attention to areas between fingers; - Rinse hands lowered to allow soiled water to drain into sink; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the dumspters were closed at all times and maintained to keep pests out and/or keep garbage contained in the dumpster. The facility's census was 62. Review of the facility's policy titled, Waste Disposal, dated May 2015, showed: - Dumpster lids are to be closed at all times; - Dumpster and dumpster area are to be kept clean and free of debris. Observations of the dumpster showed: - On 10/09/24 at 2:41 P.M., the back right lid was concaved/bent, not covering the dumpster and the front left lid not closed; - On 10/10/24 at 8:17 A.M., lids on both left and right front of the dumpster not closed and trash bags overflowing; - On 10/10/24 at 1:19 P.M., lids on both left and right front of the dumpster not closed and trash bags overflowing; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 56. Review of the facility's policy titled, Nutrition and Dining Services Manual Guidelines, dated April 2011, showed: - It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; - Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posted in the Dietary Department; - The employee will initial in the column under the day the task is completed; - Purpose is to develop detailed cleaning schedules to ensure sanitation is at acceptable standards; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dignity of three residents (Resident #4, #37, #39) out of three sampled residents with a properly covered urinary catheter bag (a bag for collecting urine from a tube inserted in the bladder). The facility census was 56. Review of the facility's policy titled, Resident Rights, dated March 2017, showed: - The resident has the right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the facility; - The resident has a right to confidentiality, privacy and respect. 1. Review of Resident #4's medical record showed: - admission date of 06/27/23; - Diagnoses of congestive heart failure (a condition in which the heart doesn't pump blood adequately) and obstructive and reflux uropathy (when urine cannot drain through the urinary tract); [...]

Inspectors wroteBased on interview and record review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) when Medicare covered services had ended for two residents (Resident #11 and #44) out of three sampled residents. The facility census was 56. Review of the facility's policy titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN), not dated, showed: - Medicare requires SNF's to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, had been completed in a timely manner, for two residents (Resident #209 and #210) out of 14 sampled residents and two residents (Resident #15 and #21) outside the sample. The facility's census was 56. The facility did not provide a MDS policy. 1. Review of Resident #15's medical record showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - An annual MDS, dated [DATE], 150 days late. Review of Resident #21's medical record showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - An annual MDS, dated [DATE], 156 days late. Review of Resident #209's medical record showed: - admitted on [DATE]; - No documentation of an admission MDS; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, within the required timeframe for one resident (Resident #8) outside the 14 sampled residents. The facility's census was 56. The facility did not provide a MDS policy. 1. Review of Resident #8's medical record showed: - An admission date of 10/33/16; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. During an interview on 07/27/23 at 9:30 A.M., the MDS Coordinator said she had submitted the MDS on time. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for one resident (Resident #7) out of 14 sampled residents. The facility census was 56. The facility did not have a MDS policy, they follow the RAI manual. 1. Review of Resident #7's quarterly MDS, dated [DATE], showed: - The resident received an anticoagulant (a blood thinner or medications that delay blood from clotting). Record review of the resident's July 2023 Physician Order Sheet (POS) showed: - An order for aspirin enteric coated 81 milligram (mg) tablet by mouth daily, dated 2/13/23; - An order for Plavix (an antiplatelet drug used to prevent blood clots) 75 mg tablet by mouth daily, dated 2/13/23; - No order for an anticoagulant medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to document weekly skin assessments and to document the status of the residents' pressure ulcers weekly for two residents (Resident #4 and #52) out of four sampled residents. The facility census was 56. Review of the facility's policy titled, Wound Care and Treatment, dated 07/2015, showed: - On-going skin assessment with weekly documentation of status. 1. Review of Resident #4's medical record showed: - An admission date of 06/27/23; - No documented skin assessment upon admission. - Diagnoses of abnormal weight loss, cerebral infarction (stroke) and neuropathy (nerve pain); - A Braden scale (a tool that was developed to help health professionals assess a patient's risk of developing a pressure ulcer) with a score of 15 (15-18 at risk), dated 06/27/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of light fixtures, using wax warmers throughout the facility, and having two broken skylight windows overhead. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 56. Review of the facility's policy titled, Environmental Safety and Health, dated May 2006, showed: - The Facility Safety and Health Committee with environmental safety in mind will work toward maintaining a safe work environment and control unsafe actions; - Will conduct periodic safety audits of specific areas of the workplace. 1. Observations on 07/24/23 at 8:00 P.M., and 07/25/23 at 10:10 A.M., of room [ROOM NUMBER] showed: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman (a person who investigates, reports on, and helps settles complaints, and who serves as an advocate for the residents) program that was readily available to residents in the facility. The facility census was 56. Review of the facility's policy titled, Resident Rights, dated 03/2017, showed: - The facility will inform the resident and/or resident representative of his/her rights and make arrangements for compliance with all written rights. Forty federal regulations address resident rights. The resident rights are available in handouts/brochures and will be discussed with the residents on one on one basis, during resident council, during activities and with outside agencies like an Ombudsman; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing data with all the required components in a clear and readable format in a prominent place readily accessible to residents and visitors on a daily basis. The facility's census was 56. The facility did not provide a nurse staffing policy. Observations showed: - On 07/24/23 at 7:30 P.M., no documentation of nurse staffing posted; - On 07/25/23 at 9:00 A.M., no documentation of nurse staffing posted; - On 07/26/23 at 10:00 A.M., no documentation of nurse staffing posted; - On 07/27/23 at 9:00 A.M., no documentation of nurse staffing posted. During an interview on 07/26/23 at 4:00 P.M., the Director of Nursing (DON) said the posting of the staff was located under the dry erase boards on both the 100 and 200 hall. [...]