Cycle 1
Health 2024-10-11 · Fire 2024-10-11
7 health deficiencies
Top issue: Administration (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Potosi, MO
Potosi Manor
1-star overall rating with 3-star inspections with $13,627 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
307 South Highway 21, Potosi, MO
(573) 438-3225
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1997-08-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.98
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,463
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Performance 7.71% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0.73
Baseline 55.88% · Performance 60.71% · Measure score 0.73 · Achievement 0.73 · Improvement 0
Adjusted total nurse staffing
0.74
Baseline 3.11 hours · Performance 3.29 hours · Measure score 0.74 · Achievement 0.74 · Improvement 0.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.38% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 19.23% · Lower 95% interval 8.61% |
| Discharge to community | 44.08% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 32.5% · Lower 95% interval 30.89% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 11.11% |
0.77%
10.3 pts worse
|
Numerator 3 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 1 · Denominator 27 · Adjusted rate 3.44% |
| Healthcare-associated infections requiring hospitalization | 7.72% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 78 |
| Staff flu vaccination coverage | 0.85% |
42%
41.1 pts worse
|
Numerator 1 · Denominator 118 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
84.8%
13.4 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.4% · Q3 98.1% · Q4 98.1% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
4.1%
1.4 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 3.7% · Q4 5.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
14.7%
11.3 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.5%
1.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 5.1% · Q4 2.7% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.6% |
25.3%
6.3 pts worse
|
19.6%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 31.2% · Q3 36.6% · Q4 37.8% · 4Q avg 31.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.1% |
25.0%
3.1 pts worse
|
16.7%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 26.5% · Q3 35.3% · Q4 24.1% · 4Q avg 28.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 34.8% |
20.3%
14.5 pts worse
|
16.3%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
19.8%
2.4 pts better
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 19.1% · Q3 17.9% · Q4 16.7% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.4%
1.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.6%
1.7 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.0% |
18.1%
4.1 pts better
|
19.8%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 15.0% · Q3 17.8% · Q4 13.8% · 4Q avg 14.0% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.0%
1.5 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 12.5% · Q3 3.2% · Q4 7.7% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.4% |
66.4%
1 pts better
|
81.7%
14.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 57.1% · Q3 85.0% · 4Q avg 67.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.5% |
63.5%
1 pts worse
|
79.7%
17.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-02-26 · Fire 2021-02-26
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-22
F · Potential for more than minimal harm
2023-07-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-09-10
F · Potential for more than minimal harm
2023-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-10
F · Potential for more than minimal harm
2023-07-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-10
E · Potential for more than minimal harm
2021-02-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-03-05
Inspection history
Recent health citations
J · Immediate jeopardy
2024-10-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-10-11
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-11
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
C · Minimal harm
2024-10-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-22
F · Potential for more than minimal harm
2023-07-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-07-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-07-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-07-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-07-27
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-07-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-07-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-07-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-10
C · Minimal harm
2023-07-27
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-09-10
C · Minimal harm
2023-07-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-10
D · Potential for more than minimal harm
2021-02-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-04-02
D · Potential for more than minimal harm
2021-02-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-04-02
D · Potential for more than minimal harm
2021-02-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-04-02
Penalties and ownership
What sits behind the stars
$13,627
2024-10-11
Fine
Fine · fine $13,627
Fine
Ownership
Lincoln, James
5% Or Greater Direct Ownership Interest · Individual
Lincoln, Judy
5% Or Greater Direct Ownership Interest · Individual
Bysor, Brandon
Corporate Director · Individual
Crane, Gary
Corporate Director · Individual
Drake, Timothy
Corporate Officer · Individual
Lincoln, James
Corporate Director · Individual
Smith, Melissa
W-2 Managing Employee · Individual
Stutts, Charlotte
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Gardens Health And Rehab, The
Potosi, MO
1-star overall rating with 3-star inspections with $8,021 in total fines with 19 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
St Joe Manor
Bonne Terre, MO
2-star overall rating with 4-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Desloge
Desloge, MO
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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