Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Monroe Manor during CMS and state inspections, most recent first.
Staff failed to follow infection control and EBP practices for residents with urinary catheters, wounds, incontinence, and oxygen therapy. A CNA emptied a catheter bag without a gown or face protection, skipped hand hygiene between glove changes, handled clean items with contaminated gloves, and allowed catheter tubing to drag on the floor while transporting a resident. Other staff were observed leaving catheter tubing on the floor, not storing oxygen tubing in a bag, performing dressing changes without proper glove changes and hand hygiene, and handling soiled linens against the body and onto the floor.
An LPN failed to follow the ordered wet-to-dry dressing technique for a resident with a surgically related infected knee wound. The wound was cleaned multiple times with the same gauze, and a 2x2 dressing was moistened with wound cleanser instead of saline and not fully saturated before being applied, despite the resident’s history of knee infection and ongoing daily dressing orders.
Incomplete Perineal Care and Foreskin Repositioning: Two residents who relied on staff for ADL assistance did not receive complete hygiene care. One resident with urinary and fecal incontinence was cleaned only in the rectal area after toileting, with the front perineal area left uncleaned before a new brief was applied. Another resident with a suprapubic catheter had the foreskin retracted for genital care, but a CNA did not return it to the normal position afterward; staff later acknowledged the missed care.
A resident with Alzheimer's disease frequently wandered and touched items with unclean hands, including other residents' belongings and food, without staff intervention for hand hygiene. Despite the care plan addressing inappropriate behaviors, it lacked specific hand hygiene measures. Staff interviews revealed challenges in maintaining sanitation, and observations showed a lack of consistent staff action to clean the resident's hands or the items they touched.
The facility failed to follow physician orders and document care for three residents, leading to deficiencies in wound care, lab monitoring, and dressing changes. A resident with a significant wound history did not receive weekly skin assessments or a follow-up urinalysis. Another resident with hypokalemia and an ileus did not have timely lab monitoring, and a third resident's discharge orders for dressing changes were not transcribed, resulting in missed care.
The facility failed to notify physicians of condition changes for two residents, one with increased confusion and abdominal issues, and another with behavioral symptoms and a missed urine test. Despite family notification, there was no documentation of physician contact until a lab result prompted action. Interviews revealed a lack of communication and documentation, with no policy guiding physician notification.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to follow infection prevention and control practices for multiple residents who had urinary catheters, wounds, oxygen therapy, or enhanced barrier precautions (EBP). The report states that staff did not consistently use gowns, gloves, hand hygiene, or face protection during high-contact care, and that catheter tubing and oxygen tubing were not kept off the floor or properly stored when not in use. The facility’s policies and CDC guidance cited in the report required hand hygiene before and after resident contact, after glove removal, and during invasive device care, and required EBP for residents with indwelling devices or wounds during activities such as dressing, bathing, toileting, and linen changes. For one resident with pneumonia, sepsis, influenza A, acute respiratory failure, and a urinary catheter, an oxygen concentrator was observed running with the nasal cannula and tubing lying on the floor on multiple occasions. During morning care, a CNA emptied the catheter bag without a gown or face protection, removed gloves without hand hygiene, changed the resident’s clothing while handling the catheter bag and oxygen tubing, dropped the catheter bag on the floor multiple times, and later pushed the resident in a wheelchair while the catheter tubing dragged on the floor down the hallway. The same resident’s catheter tubing was also observed on the floor in the room and dining room, and the oxygen tubing was later observed lying across the bedside table and on the floor when the resident was not in the room. For another resident with a suprapubic catheter and severe cognitive impairment, catheter tubing was observed lying directly on the fall mat beside the bed while staff provided care. A CNA entered the room, put on gloves and a gown, emptied the catheter without face protection, removed gloves without hand hygiene, and then touched clean items and the resident’s clothing with the same contaminated gloves. For a resident with bowel and bladder incontinence, a CNA performed incontinence care, then without removing gloves touched the clean brief, clothing, lift controls, wheelchair, tablet, and headphones before removing gloves and leaving the room without hand hygiene. For a resident with continuous oxygen, the portable oxygen tubing was repeatedly observed coiled over the regulator or hanging freely and not stored in a bag, and the resident was often not wearing oxygen. The report also describes wound care and linen-handling failures. For a resident with an infected knee arthroplasty and daily wet-to-dry dressing changes, an LPN removed the old dressing, changed gloves without hand hygiene, cleaned the wound, and then applied the new dressing without changing gloves after wound cleansing. For a resident with pressure injuries, a surgical wound, and a skin tear who required EBP, a CNA handled dirty bed linens without a gown, held the linens against the body, carried them outside the room, and placed them directly on the floor before putting them into a trash bag. The DON and other staff interviewed in the report acknowledged that catheter tubing should not touch the floor, dirty gloves should not touch clean surfaces, hand hygiene should occur after glove removal, and dirty linens should not be carried against the body or placed on the floor.
Improper Wet-to-Dry Dressing Change for Surgical Knee Wound
Penalty
Summary
The facility failed to follow professional standards of quality and its own dressing-change procedure for a resident with a surgical wound on the right knee. The resident had a history of right total knee arthroplasty complicated by infection, including prior open debridement, positive cultures for Staph epidermidis, and a later surgery with replacement of the plastic in the joint. Physician orders directed a wet-to-dry dressing with 2x2 gauze, ABD dressing, and ace wrap daily, and the care plan directed daily dressing changes using aseptic technique. The resident also had a stable 2.7 cm by 3 cm lesion on the right knee and reported that the wound was related to the prior knee infection and that IV antibiotics had been discontinued. During observation of the dressing change, an LPN removed the old dressing and then cleaned the wound by wiping over it multiple times with the same 2x2 gauze. The LPN moistened a clean 2x2 dressing with wound cleanser instead of normal saline and placed it on the wound without saturating it, then covered it with an ABD pad, secured it with gauze cling, and wrapped the leg with an ace bandage. The LPN stated the dressing was supposed to be soaked in normal saline but none was available, and that the order did not specify what to use, so wound cleanser was used instead.
Incomplete Perineal Care and Foreskin Repositioning
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for two residents who depended on staff for toileting hygiene and perineal care. One resident had urinary and fecal incontinence and was dependent on staff for toileting and personal hygiene. During observation, the resident was assisted to the toilet while the incontinence brief and pants were soiled with urine, and after the resident had a bowel movement, the staff cleaned the rectal area but did not clean the front perineal area before putting on a new brief and clothing. Staff later stated they were not aware the front perineal area had not been cleaned, and one staff member said the other should have provided the peri-care because the resident was incontinent of urine. A second resident had a suprapubic catheter and was limited in the ability to maintain grooming and personal hygiene due to stroke and decreased mobility. During observation, a CNA retracted the resident’s foreskin to clean the genital area but did not return the foreskin to its normal position afterward. One CNA stated they did not know the foreskin had to be repositioned after care, while another said they knew it needed to be put back but did not notice it had not been done. The DON stated staff should clean both the front and back perineal areas when a resident is incontinent of urine and should reposition the foreskin after care for a male resident.
Failure to Ensure Hand Hygiene for Resident with Dementia
Penalty
Summary
The facility failed to ensure proper hand hygiene for a resident diagnosed with Alzheimer's disease, who exhibited behaviors such as wandering, incontinence, and inappropriate touching of genitals. The resident frequently placed their hands in their pants and touched various items around the unit, including other residents' belongings, meal trays, and food items, without staff intervention to provide hand hygiene. Despite the resident's care plan addressing socially inappropriate behaviors, it lacked specific interventions for hand hygiene related to the resident's behavior. Observations revealed that the resident continued to wander with their hands in their pants, touching other residents and items without staff redirection or hand hygiene assistance. Staff interviews indicated difficulty in maintaining sanitation due to the resident's behaviors, and there was a lack of consistent staff intervention to clean the resident's hands or the items they touched. The facility's policy on hand hygiene was not effectively implemented, as staff did not consistently sanitize high-touch areas or ensure the resident's hands were cleaned after contact with genitals or other items. Interviews with staff and residents highlighted the impact of the resident's behaviors on the facility environment, with other residents expressing discomfort and staff acknowledging challenges in keeping areas sanitized. The Director of Nursing noted attempts to educate staff on hand hygiene, but the deficiency persisted, indicating a failure to adequately monitor and address the resident's hygiene needs in accordance with the facility's policy.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to ensure that three residents received care and services according to physician's orders and professional standards. Resident #2, who had a significant wound and skin history, did not have weekly skin assessments completed and documented as ordered. Additionally, a follow-up urinalysis ordered on 08/01/24 was not obtained. The facility also failed to document attempts to collect the urine sample or notify the physician of the inability to collect it. Interviews with staff revealed a lack of documentation and communication regarding the resident's care refusals. Resident #1, who had a diagnosis of hypokalemia and an ileus, did not have labs obtained as ordered to monitor potassium levels. The facility failed to follow up timely on lab results, which were delayed due to issues with the lab company. The resident's potassium supplement was not administered as ordered due to unavailability, and there was a lack of documentation regarding the ordered labs and follow-up actions. The delay in obtaining and reporting lab results led to a gap in the resident's treatment. Resident #3's discharge orders for dressing changes around a biliary drain tube and a g-tube were not transcribed into the facility's orders, resulting in missed dressing changes. The resident reported uncertainty about when the dressings were last changed, and observations confirmed drainage and odor from the dressings. The DON acknowledged the oversight in transcribing the orders, which led to the deficiency in care for Resident #3.
Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician of changes in condition for two residents, leading to a deficiency. For the first resident, who was admitted for rehabilitation and had a history of dementia and congestive heart failure, staff did not inform the physician about increased confusion and abdominal distension observed on multiple occasions. Despite the resident's family being notified of the decline, there was no documentation of physician notification until a lab result prompted a call to the physician, after which the family decided to transport the resident to the hospital. The second resident, who exhibited behavioral symptoms and had a severely impaired cognition, was not properly managed as staff failed to notify the physician about increased behaviors and the inability to obtain a urine sample as ordered. The resident's behaviors included verbal outbursts, wandering, and hallucinations, which were not communicated to the physician, and the urine sample was not collected due to the resident's delusional state. The resident was eventually sent to the hospital for evaluation without prior physician notification of these issues. Interviews with staff, including the DON and RN, revealed a lack of documentation and communication regarding the residents' changes in condition. The DON expected staff to notify physicians of any changes, but there was no policy in place for when to notify physicians, contributing to the oversight. The residents' physicians confirmed they were not informed of the changes, highlighting a communication breakdown within the facility.
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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 Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baptist Homes Of Shelbina | 15.4 mi | ★★★★★ | 1 | 0 |
| Monroe City Manor Care Center | 18.8 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Nursing Center | 19.2 mi | ★★★★★ | 1 | 0 |
| Pin Oaks Living Center | 21.2 mi | ★★★★★ | 10 | 0 |
| Valley View Health & Rehabilitation | 22.7 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 August 2026) and official state health department websites.