Inspection Reports for
Monroe City Manor Care Center
1010 HIGHWAY 24 & 36 EAST, MONROE CITY, MO, 63456-1116
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
90% occupied
Based on a August 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 54
Deficiencies: 4
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards including residents' financial management, medication administration, food safety, and vaccination policies at Monroe City Manor Care Center.
Findings
The facility failed to prevent negative balances in residents' trust accounts, administered incorrect medication dosages, improperly applied eye drops, had unsanitary kitchen conditions including grease buildup and improper food storage, and did not ensure residents were up to date on pneumococcal vaccinations according to CDC guidelines.
Deficiencies (4)
F 0567: The facility failed to prevent residents' trust accounts from going into negative balances, affecting one resident. The system for cash disbursement was inadequate, allowing withdrawals beyond available funds.
F 0658: The facility failed to follow physician orders for medication administration, resulting in a resident receiving the wrong dose of fluoxetine. Staff also failed to apply pressure to the inner canthus after administering eye drops as per manufacturer instructions.
F 0812: The facility failed to maintain kitchen sanitation, with grease and debris buildup on range hood filters and floors, and improper food storage such as ice cream mix stored directly on the floor and uncovered butter.
F 0883: The facility failed to offer or administer pneumococcal vaccinations according to CDC guidelines for three residents, and did not adequately track vaccination status.
Report Facts
Facility census: 54
Petty cash vouchers sum for Resident #40 in March: 105
Petty cash vouchers sum for Resident #40 in April: 80
Petty cash vouchers sum for Resident #40 in May: 75
Fluoxetine 20 mg capsules delivered on 07/24/25: 2
Fluoxetine 10 mg capsules delivered on 07/24/25: 15
Fluoxetine 20 mg capsules delivered on 08/11/25: 15
Number of sampled residents for medication review: 17
Number of sampled residents for trust account review: 7
Number of sampled residents for vaccination review: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in medication administration and eye drop application findings |
| LPN D | Licensed Practical Nurse | Named in medication transcription and administration findings |
| Director of Nursing | Director of Nursing | Provided interviews regarding medication and vaccination policies |
| Administrator | Facility Administrator | Provided interviews regarding trust account management, medication administration, and vaccination expectations |
| Dietary Manager | Dietary Manager | Provided interviews regarding kitchen sanitation and food storage |
| Business Office Manager | Business Office Manager | Named in trust account cash disbursement process |
| Receptionist | Receptionist | Named in trust account cash disbursement process |
| MDS Coordinator | MDS Coordinator | Named in vaccination tracking process |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 4
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as an annual survey of Monroe City Manor Care Center to assess compliance with federal and state regulations regarding nursing staffing, nutritional needs, food safety, and bed safety.
Findings
The facility was found deficient in posting accurate nurse staffing information, meeting nutritional needs of residents, maintaining food safety standards, and conducting regular inspections of bed frames and rails. Several deficiencies were cited with varying severity levels.
Deficiencies (4)
F732 Nurse Staffing Information: The facility failed to post total nursing staff hours worked per shift and did not document total staff hours on posted staffing sheets. The facility census was 54.
F803 Menus and Nutritional Adequacy: The facility failed to ensure meals met nutritional needs; staff did not prepare and serve food according to the diet spreadsheet menu. The facility census was 54.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure dietary equipment was clean and free of grease, dust, and debris. The facility census was 54.
F909 Resident Bed: The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify entrapment risks and ensure compatibility for five residents. The facility census was 54.
Report Facts
Facility census: 54
Number of beds in use: 17
Inspection Report
Life Safety
Census: 54
Capacity: 60
Deficiencies: 12
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and emergency preparedness regulations at Monroe City Manor Care Center.
Findings
The facility was found deficient in multiple areas including emergency preparedness policies, delayed egress locking signage, range hood operation, sprinkler system maintenance, smoke barrier integrity, corridor door maintenance, HVAC ventilation, smoking regulations, electrical equipment maintenance, and oxygen storage safety. These deficiencies had the potential to affect residents in various smoke compartments.
Deficiencies (12)
E024 Policies and procedures. The facility failed to ensure the emergency preparedness manual included policies for the use of volunteers and role strategies during emergencies. The facility census was 54.
K222 Egress Doors. The facility failed to post proper signage for delayed egress locking on an emergency exit door, potentially affecting 21 residents in the 200 Hall and special care unit.
K324 Cooking Facilities. The facility failed to ensure proper operation of the range hood by allowing gaps between baffle filters, potentially affecting residents and staff in one of five smoke compartments.
K353 Sprinkler System - Maintenance and Testing. The facility failed to maintain sprinkler heads free from debris and ensure the annular space was properly sealed, potentially affecting 36 residents in four smoke compartments.
K363 Corridor Doors. The facility failed to maintain corridor doors to resist smoke passage, with visible gaps around doors potentially affecting all 54 residents in three smoke compartments.
K372 Subdivision of Building Spaces - Smoke Barrier Construction. The facility failed to maintain smoke barriers to ensure completeness, potentially affecting 21 residents in the 200 Hall and other areas.
K374 Subdivision of Building Spaces - Smoke Barrier Doors. The facility failed to ensure doors and frames within smoke barriers were properly labeled and self-closing, potentially affecting 54 residents in five smoke compartments.
K521 HVAC. The facility failed to ensure exhaust ventilation units were free from dust and debris, potentially affecting 54 residents in three smoke compartments.
K741 Smoking Regulations. The facility failed to maintain smoking areas free of cigarette butts and ensure proper disposal containers, potentially affecting residents and staff in five smoke compartments.
K920 Electrical Equipment - Power Cords and Extension Cords. The facility failed to prohibit multi-plug adapters and extension cords, potentially affecting 54 residents in four smoke compartments.
K921 Electrical Equipment - Testing and Maintenance. The facility failed to provide complete documentation of electrical receptacle assessments and ensure failed receptacles were replaced, potentially affecting 54 residents in five smoke compartments.
K923 Gas Equipment - Cylinder and Container Storage. The facility failed to ensure oxygen storage enclosure was made of non-combustible construction and properly maintained, potentially affecting 33 residents in two smoke compartments.
Report Facts
Facility census: 54
Facility capacity: 60
Residents potentially affected: 21
Residents potentially affected: 36
Residents potentially affected: 54
Residents potentially affected: 33
Inspection Report
Routine
Census: 54
Deficiencies: 4
Date: Nov 16, 2023
Visit Reason
Routine inspection to assess compliance with nursing staff posting requirements, dietary services, food safety, and bed rail safety.
Findings
The facility failed to post total nursing staff hours per shift, served incorrect dessert portions for diabetic residents, had unsanitary dietary equipment and storage practices, lacked an ice machine drainage air gap, and did not conduct proper inspections of bed rails, mattresses, and bed frames for safety and entrapment risks.
Deficiencies (4)
F0732: The facility failed to post total nursing staff hours worked for each shift, posting only staff counts. The census was 54.
F0803: The facility failed to serve meals according to diet orders, serving the same dessert portion to all residents including diabetics on a consistent carbohydrate diet. The census was 54.
F0812: The facility failed to maintain dietary equipment free of grease, dust, and debris, failed to remove damaged food containers, failed to seal and date opened packages, and lacked an ice machine drainage air gap. The census was 54.
F0909: The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify entrapment risks and ensure compatibility for five residents with bed rails. The census was 54.
Report Facts
Facility census: 54
Number of residents with CCHO diet: 10
Number of beds with bed rails observed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Interviewed about staffing sheet completion and posting practices |
| Director of Nurses | Director of Nursing | Interviewed about staffing sheet completion and bed rail maintenance expectations |
| Dietary Aide C | Dietary Aide | Interviewed about dessert serving practices |
| Dietary Manager | Dietary Manager | Interviewed about dietary staff compliance with diet menus and cleaning expectations |
| Registered Dietitian | Registered Dietitian | Interviewed about dietary menu compliance and cleaning expectations |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about ice machine air gap and bed rail maintenance practices |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about monthly bed and mattress inspections |
| Nurse Manager | Nurse Manager | Interviewed about bed rail maintenance program and documentation |
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a facility's failure to implement its cardiopulmonary resuscitation (CPR) policy, including failure to initiate CPR for a resident with full code status.
Findings
The facility failed to implement its CPR policy and did not initiate CPR for a resident who was unresponsive and without pulse or respirations. Staff lacked knowledge of residents' full code status and proper CPR procedures, resulting in a resident's death without CPR being performed.
Deficiencies (1)
F 678 Cardio-Pulmonary Resuscitation (CPR) policy was not implemented correctly. Staff failed to initiate CPR for a resident with full code status who was found unresponsive and without pulse or respirations.
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in the CPR policy failure and resident care events |
| CNA G | Certified Nurse Aide | Named in the CPR policy failure and resident care events |
| RN C | Registered Nurse | Named in the CPR policy failure and resident care events |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement their CPR policy and failure to initiate CPR for a full code resident who was found unresponsive and expired at the facility.
Complaint Details
The complaint investigation found that staff failed to initiate CPR on a full code resident who was found unresponsive and without a pulse. The resident expired at the facility. Staff interviews revealed lack of knowledge about CPR policy and resident code status. The administrator acknowledged facility failure in identifying full code residents and expected CPR initiation by certified staff.
Findings
The facility failed to initiate CPR for one full code resident found unresponsive without a pulse or respirations, resulting in the resident's death. Staff were unaware of residents' code status and did not follow CPR procedures as required by facility policy.
Deficiencies (1)
F 0678: The facility failed to implement their CPR policy and did not initiate CPR for a full code resident found unresponsive without a pulse or respirations. Staff were unaware of the resident's code status and did not start CPR or call 911 as required.
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in failure to initiate CPR and lack of knowledge of resident code status |
| CNA G | Certified Nurse Aide | CPR certified staff who found the resident unresponsive but did not initiate CPR |
| RN C | Registered Nurse | Interviewed regarding the incident and CPR initiation expectations |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 4
Date: Aug 5, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding the management and protection of residents' personal funds.
Findings
The facility was found to have deficiencies in the management and protection of residents' personal funds, including unauthorized withdrawals and failure to provide quarterly statements to residents or their guardians.
Deficiencies (4)
F 567 Protection/Management of Personal Funds: The facility failed to use residents' personal funds exclusively for them and only with written authorization for three residents. Unauthorized withdrawals and use of funds without resident or guardian consent were documented.
F 568 Accounting and Records of Personal Funds: The facility failed to provide quarterly statements showing all transactions to residents or their guardians for two residents. The system did not assure full and separate accounting of residents' personal funds.
A9002 Resident Fund Use: The operator did not use the personal funds exclusively for the resident or only when authorized in writing. The regulation was not met as evidenced by findings in F567.
A9009 Resident Funds Reconciled Monthly: The facility failed to reconcile residents' funds monthly and provide written statements quarterly as required. The deficiency was linked to F568.
Report Facts
Facility census: 57
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| B. Vanlandingham | LNHA | Signed plan of correction and facility representative |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and an Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Report Facts
Regulatory compliance references: 42
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 5
Date: Nov 11, 2020
Visit Reason
The inspection was conducted to assess compliance with food safety requirements, including food procurement, storage, preparation, and serving sanitary standards at Monroe City Manor Care Center.
Findings
The facility failed to maintain the walk-in freezer temperature at 0 degrees Fahrenheit or below, did not label and date food items properly, prepared food on the steam table contrary to standards, had ice machines with debris buildup, and failed to wash fresh produce prior to preparation. Multiple observations confirmed these deficiencies.
Deficiencies (5)
F812 Food safety requirements were not met as the walk-in freezer temperature was above 0 degrees Fahrenheit, food items were not labeled or dated, food was prepared on the steam table, ice machines had debris buildup, and fresh produce was not washed prior to preparation.
A7015 Food must be protected from contamination and held at proper temperatures; this regulation was not met as referenced in F812.
A7022 Frozen food must be kept at zero degrees Fahrenheit or below; this regulation was not met as referenced in F812.
A7027 Raw fruits and vegetables must be thoroughly washed with potable water before cooking or serving; this regulation was not met as referenced in F812.
A7050 Food-contact surfaces must be clean and free of defects; this regulation was not met as referenced in F812.
Report Facts
Facility census: 48
Inspection Report
Life Safety
Census: 48
Capacity: 60
Deficiencies: 2
Date: Nov 11, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association, focusing on smoke barrier doors and fire safety regulations.
Findings
The facility failed to maintain doors in smoke barriers to preserve a 20-minute fire resistance rating and resist smoke passage. Door frames had holes and labels were painted over, compromising fire safety measures affecting 36 residents in three smoke compartments.
Deficiencies (2)
K374: The facility failed to maintain doors in smoke barriers to preserve a 20-minute fire resistance rating and resist smoke passage. Door frames had pencil-sized holes and labels were covered with paint, making them illegible.
A2054: Each smoke section shall be separated by one-hour fire-rated walls and doors that are at least 20-minute fire rated and self-closing. This regulation was not met as evidenced by the deficiencies in smoke section walls and doors.
Report Facts
Residents affected: 36
Facility capacity: 60
Census: 48
Inspection Report
Routine
Census: 48
Deficiencies: 6
Date: Nov 11, 2020
Visit Reason
The inspection was conducted to evaluate compliance with food safety and sanitation standards in the facility's kitchen and food storage areas.
Findings
The facility failed to maintain the walk-in freezer temperature at 0 degrees Fahrenheit or below, did not label and date food items properly, prepared food on the steam table contrary to guidelines, had ice machines with debris buildup, failed to wash fresh produce before preparation, and had cookware with heavy buildup of black debris that was not easily cleanable.
Deficiencies (6)
F0812: The walk-in freezer temperature was consistently above 0 degrees Fahrenheit, ranging from 6 to 11 degrees F during October and November 2020, exceeding the required 0 degrees F or below.
Food items in dry storage and refrigerators, including tortilla shells, pimento cheese, waffles, and donuts, were found open and not labeled or dated as required.
Instant mashed potatoes were prepared directly on the steam table, which is not an approved method of food preparation.
Two ice machines had accumulations of crusty white and black debris around hinges and discharge areas, indicating inadequate cleaning.
Fresh produce, such as tomatoes, was not washed prior to food preparation and serving to residents.
Cookware including a red skillet and a metal wire fryer basket had heavy buildup of black carbon-like debris covering significant surfaces and were not easily cleanable.
Report Facts
Facility census: 48
Walk-in freezer temperatures: 6
Walk-in freezer temperatures: 11
Food storage temperature requirement: 0
Instant mashed potatoes package size: 26
Cookware coverage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding freezer temperatures, food labeling, food preparation, ice machine cleaning, and produce washing | |
| Dietary Staff A | Observed preparing instant mashed potatoes on steam table and placing tomato slices on resident trays | |
| Dietary Staff B | Observed slicing unwashed tomato for food preparation | |
| Maintenance Supervisor | Interviewed regarding responsibility and schedule for cleaning ice machines |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Report Facts
Regulation reference: 42
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 2
Date: Mar 27, 2019
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations, focusing on the facility's environment and medication administration practices.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to heavy buildup of debris on exhaust fans and vents. Additionally, the facility did not ensure residents were free of significant medication errors, specifically improper insulin administration.
Deficiencies (2)
F584 Safe/clean/comfortable/homelike environment was not maintained due to heavy buildup of debris on multiple exhaust fans and ceiling vents throughout the facility.
F760 Residents were not free of significant medication errors as staff failed to properly prime insulin pens before administration, risking incorrect dosing.
Report Facts
Facility census: 55
Sampled residents for medication review: 15
Completion date for plan of correction: Apr 30, 2019
Exhaust fan cleaning completion date: Apr 8, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra L. Edris | Laboratory Director or Provider/Supplier Representative | Signed the inspection report and plan of correction |
| Director of Nursing | Interviewed regarding insulin pen priming procedures | |
| Registered Nurse (RN) A | Observed administering insulin without priming the pen | |
| Registered Nurse (RN) B | Observed administering insulin without priming the pen | |
| Maintenance Supervisor | Interviewed about cleaning schedule for exhaust fans |
Inspection Report
Life Safety
Census: 55
Capacity: 60
Deficiencies: 3
Date: Mar 27, 2019
Visit Reason
The visit was conducted as a Life Safety Code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to ensure smoke barriers in the attic were complete, with unsealed penetrations compromising smoke compartments. This deficiency potentially affected 16 residents and others in multiple areas of the building.
Deficiencies (3)
42 CFR 483.90(a) The facility does not meet the applicable provisions of the 2012 Life Safety Code. The facility failed to ensure smoke barriers in the attic were complete from outside wall to outside wall and from floor to roof deck, compromising smoke compartments.
Subdivision of Building Spaces - Smoke Barrier Construction. The facility had unsealed holes and flexible conduits passing through smoke barriers in the attic, allowing passage of smoke and fire, affecting 16 residents and multiple areas.
19 CSR 30-85.022(29) Smoke Section Walls/Doors. Each smoke section must be separated by one-hour fire-rated walls and doors. This regulation was not met as evidenced by the deficiencies noted in K372.
Report Facts
Residents potentially affected: 16
Building capacity: 60
Census: 55
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 3
Date: May 25, 2018
Visit Reason
The inspection was conducted to evaluate food safety and sanitation practices at Monroe City Manor Care Center, focusing on proper food procurement, preparation, and handling procedures.
Findings
The facility failed to ensure proper food sanitation practices, including staff handling frozen hamburger patties and bacon with bare hands without washing. Employees did not consistently wear gloves when handling raw or frozen foods, posing a risk of contamination.
Deficiencies (3)
F812 Food safety requirements were not met as staff handled frozen hamburger patties and bacon with bare hands without washing, risking contamination.
A7002 Employees did not thoroughly wash hands and exposed arms with soap and warm water before work and as needed, failing to keep fingernails clean and trimmed.
A7015 Food must be protected from contamination and maintained at safe temperatures; the facility failed to ensure this protection.
Report Facts
Facility census: 56
Inspection Report
Life Safety
Census: 56
Capacity: 60
Deficiencies: 4
Date: May 25, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to meet requirements for smoke detection systems and smoke barriers, including unsealed openings and lack of smoke detectors in certain areas. No deficiencies were found in the emergency preparedness investigation.
Deficiencies (4)
K347 Smoke Detection: The facility failed to ensure spaces open to the corridor were properly equipped with smoke detection systems, including a window without a smoke seal and no smoke detectors in the business office.
K372 Smoke Barrier Construction: The facility failed to ensure smoke barriers were complete from outside wall to outside wall and from floor to roof deck, with multiple unsealed penetrations observed in various locations.
A2026 Smoke Detectors-Interconnected to Fire Alarm System: The regulation requiring smoke detectors to be interconnected to the fire alarm system was not met, as referenced by deficiency K347.
A2054 Smoke Section Walls/Doors: The requirement for smoke sections to be separated by one-hour fire-rated walls and doors was not met, as referenced by deficiency K372.
Report Facts
Facility capacity: 60
Census: 56
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