Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Monroe City Manor Care Center during CMS and state inspections, most recent first.
Kitchen sanitation and food storage deficiencies: The range hood over cooking equipment had a moderate buildup of grease and debris, and the kitchen floor had an extremely heavy buildup of pooled grease and food debris beneath the stove, griddle, fryer, and prep counter. The walk-in freezer floor had paper trash and food debris, and food items were improperly stored in the cooler and kitchenette refrigerator, including liquid ice cream mix kept on the floor and an open stick of butter left loosely covered.
Failure to track and document pneumococcal vaccination status led to three residents being listed as up to date in the MDS despite missing CDC-indicated vaccines. One resident with DM and asthma, one resident with DM, and one resident with COPD, dementia, and prior PPSV23 had no documentation of additional pneumococcal vaccines being offered, received, or refused. The DON stated the facility did not track pneumonia vaccination status, and the MDS Coordinator said a nurse who had been tracking vaccinations had quit months earlier.
A resident’s trust account was allowed to go into a negative balance after repeated petty cash withdrawals were not tracked in real time. The receptionist gave cash from the facility petty cash drawer and kept vouchers until monthly reimbursement, while the BOM only learned the accurate balance after the vouchers were turned in. Records showed the resident’s account went negative after reimbursements for prior cash withdrawals, and the resident later reported being told there was no money available.
A resident with major depressive disorder received fluoxetine at the wrong dose when staff failed to compare the MAR with the medication card and documented 10 mg while administering 20 mg. Another resident with ocular hypertension received Combigan eye drops without the required pressure applied to the inner canthus or instructions to keep the eyes closed, and liquid ran from both eyes during administration.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to ensure the kitchen range hood and baffle filters were free of accumulated grease and debris. The facility policy stated hoods and filters were to be cleaned regularly, at least once a month, but the consultant dietitian’s sanitation evaluations on 6/6/25 and 7/11/25 noted the hoods and filters were not clean and dust was present. During observation on 8/18/25 at 10:35 A.M., the range hood over the six-burner stove, flat-top griddle, and double fryer had a moderate buildup of yellow grease and dark-colored debris on the baffle filters. The Dietary Manager said staff were supposed to clean the hood and filters weekly and was unsure whether they had been cleaned the prior week. The facility also failed to keep kitchen floors and food storage areas clean and properly stored. The consultant dietitian’s evaluations noted the kitchen floor was not clean and later sticky, and observations on 8/18/25 and 8/19/25 showed an extremely heavy buildup of yellow and brown pooled grease and food debris under the stove, griddle, double fryer, and metal preparation counter, with grease running down the front of the stove into the puddle. The Dietary Manager said staff were supposed to clean the grease off the floor weekly, but staff were behind in scheduled duties. In the walk-in freezer, a heavy accumulation of paper trash, potato wedges, and other food debris/crumbs was observed on the floor. In the walk-in cooler, a black crate on the floor held a plastic bag of liquid ice cream mix that directly touched the floor, and in the kitchenette refrigerator an open 1-pound stick of butter was loosely covered by its paper wrapper and left open to air. The Dietary Manager said the ice cream mix should not be stored on the floor.
Failure to Track and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and/or administer pneumococcal vaccination in accordance with current CDC guidelines for three sampled residents. In a review of 17 residents, Residents #1, #38, and #47 were identified as not being up to date on pneumococcal immunization, despite documentation in the MDS that their vaccinations were current. The facility census was 54. Resident #38 was over age 65 and had diagnoses of diabetes mellitus and asthma. The resident’s preventive health documentation contained no record of any pneumococcal vaccinations being received, offered, or refused. Although the quarterly MDS dated 05/24/25 indicated the resident’s pneumococcal vaccinations were up to date, the resident’s representative stated the resident was expected to be current with all immunizations and believed the resident was up to date. Resident #1 was over age 65 and had diabetes mellitus. The resident had received a pneumonia vaccination of unknown type on 12/31/19, but the preventive health record contained no documentation that any additional pneumococcal vaccine was offered, received, or refused. Resident #47 was over age 65 with diagnoses including pneumonitis due to inhalation of food and vomit, COPD, altered mental status, and dementia. The resident had received PPSV23 out of the facility on 11/30/20, but there was no documentation of any additional pneumococcal vaccine being offered, received, or refused. The resident’s DPOA stated staff were expected to offer available vaccinations as needed.
Resident Trust Account Allowed to Go Negative
Penalty
Summary
The facility failed to implement policies and procedures to ensure residents’ trust accounts were not allowed to go into a negative balance, affecting one resident in a review of seven sampled residents whose accounts were maintained by the facility. The facility policy stated that when the facility manages resident funds, it acts as a fiduciary and holds, safeguards, manages, and accounts for those funds. Review of the resident trust fund statements and petty cash vouchers showed the resident signed vouchers for cash in March, April, and May, while the facility later transferred money from the resident trust account to the facility account to replace the petty cash withdrawals. The records showed the resident’s trust balance became negative after the facility reimbursed petty cash withdrawals. On 04/06/25, a $105.00 transfer was made to replace March petty cash, and the resident trust balance became -$5.00. On 05/07/25, an $80.00 transfer was made to replace April petty cash, and the balance became -$4.99. On 06/09/25, a $75.00 transfer was made to replace May petty cash, and the balance became -$79.99. The July statement showed the beginning and ending balance remained -$79.99. During interview, the resident said money for the trust account came from the spouse and that the resident always got money from the receptionist, but was told about six months earlier that there was no money available. The receptionist said she gave residents cash from the facility petty cash drawer and did not check the slips in the drawer before giving the resident money, and that the accurate balance was not known until the vouchers were turned in to the Business Office Manager once a month. The Business Office Manager and Administrator stated the receptionist gave residents money from petty cash, vouchers were turned in monthly, the resident had gone into debt, and there should have been a better system for cash disbursement.
Medication dose mismatch and improper eye drop administration
Penalty
Summary
The facility failed to follow physician orders and medication administration standards for Resident #51, who had a diagnosis of major depressive disorder and was prescribed fluoxetine. The resident’s physician orders showed fluoxetine 20 mg was discontinued and a fluoxetine 10 mg order began shortly afterward. Pharmacy records showed fluoxetine 20 mg and 10 mg capsules were delivered at different times, but the resident’s MAR documented administration of fluoxetine 20 mg on two days when the 20 mg order had been discontinued. Later, during medication administration observation, RN C pulled a fluoxetine 20 mg medication card labeled for the resident from the medication cart and stated it should not have been there and that the resident had been receiving the wrong dose. Record review and staff interviews showed the wrong dose was administered and documented. LPN D stated he/she transcribed the order to decrease fluoxetine from 20 mg to 10 mg, but did not remove the discontinued 20 mg medication card from the cart. LPN D also stated that on one occasion he/she administered fluoxetine 20 mg to the resident while documenting fluoxetine 10 mg on the MAR, and that the best practice is to compare the medication card to the MAR before administration. RN C stated he/she administered fluoxetine 20 mg on another occasion while documenting fluoxetine 10 mg on the MAR, explaining that he/she had been checking only the medication name and not the dosage. The pharmacist stated the 20 mg prescription had remained in the pharmacy system and was sent to the facility by mistake. The facility also failed to follow manufacturer instructions and professional standards when administering Combigan eye drops to Resident #2, who had bilateral ocular hypertension and was ordered Combigan drops in both eyes twice daily. During observation, RN C instilled one drop into each eye but did not apply pressure to the inner corner of the eye after administration and did not instruct the resident to close the eyes or keep them closed for a few minutes. Liquid ran under both eyes and the resident wiped it away with a tissue. RN C later stated pressure should be held at the corner of the eyelid by the nose after eye drop administration and acknowledged he/she should have educated the resident on proper administration. The DON stated staff should hold pressure on the corner of the eyelid by the nose for one to two minutes after administering eye drops.
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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 Monroe City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luther Manor Retirement & Nursing Center | 13.3 mi | ★★★★★ | 36 | 0 |
| Maple Lawn Nursing Home | 14 mi | ★★★★★ | 23 | 0 |
| Westview Nursing Home | 14.6 mi | ★★★★★ | 0 | 0 |
| Baptist Homes Of Shelbina | 16.8 mi | ★★★★★ | 0 | 0 |
| Beloved Health And Rehabilitation Center | 18.1 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.