Monroe City Manor Care Center

In the surveyor’s words

From the most serious findings on record at Monroe City Manor Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jul 5, 2023

  Based on interview and record review, the facility failed to implement their policy for cardiopulmonary resuscitation (CPR, process of providing rescue ventilation and chest compressions to maintain circulation of blood) and failed to initiate CPR for one resident (Resident #1) of four sampled residents who was identified as having full code status (CPR required in the event of cardiac or respiratory arrest), when staff found the resident unresponsive and without a pulse or respirations. The resident expired at the facility. The facility census was 54. On [DATE], the administrator was notified of a Past Noncompliance Immediate Jeopardy (IJ) which occurred on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Nov 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust and debris, failed to remove damaged food containers from the dry storage room, failed to seal/date opened packages, and failed to ensure an ice machine drain contained a drainage air gap. The facility census was 54. Review of the facility's Cleaning Rotation Policy, 2011 Edition, showed the following: -Guideline - Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions; -Items cleaned after each use included can opener, small food preparation equipment, work tables and counters; -Items cleaned daily included stove top, grill, kitchen and dining room floors, toaster, and exterior of large… […]

• No harm, potential for more than minimal, patternF812Aug 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure the range hood was free of an accumulation of grease and debris, failed to ensure the floors in the kitchen were free of a buildup of grease and debris, and failed to properly store food items. The facility census was 54.1. Review of the facility policy, Cleaning Instructions: Hoods and Filters, dated 2020, showed hoods and filters will be cleaned regularly, at least once a month. Review of the Dietary Sanitation Evaluation, dated 6/6/25 and completed by the facility's consultant dietitian, showed the hoods and filters were not clean and dust was noted. […]

• No harm, potential for more than minimal, patternF883Aug 21, 2025

  Based on interview and record review, the facility failed to offer and/or administer the pneumococcal vaccine as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for three residents (Residents #1, #38 and #47), in a review of 17 sampled residents. The facility census was 54. Review of the CDC's Pneumococcal Vaccine Timing for Adults, updated October 2024, showed the following:-For adults 50 years or older who have never received any pneumococcal vaccine or whose previous vaccination history is unknown, administer PCV15, PCV20, or PCV21; -If PCV15 is administered, administer a dose of PPSV23 at least one year after the dose of PCV15. […]

• No harm, potential for more than minimal, patternF803Nov 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure meals were served to meet the nutritional needs of the residents. Staff failed to prepare and serve food according to the diet spreadsheet menu. The facility census was 54. Review of the facility's Diet Orders Policy, 2011 Edition, showed the following: -Guideline: Each resident will have a diet order prescribed by the physician and documented in the health record. All physicians will prescribe diets using the terminology of the house diets and/or terminology in the diet manual. […]