Potosi Manor

In the surveyor’s words

From the most serious findings on record at Potosi Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 22, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF865Oct 11, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF867Oct 11, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF868Oct 11, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jul 27, 2023

  Based 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; -… […]