Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Pruitthealth - Monroe during CMS and state inspections, most recent first.
The facility did not ensure proper air drying of dishware after sanitization, as observed when a dietary cook used a paper towel to dry food processor equipment instead of allowing it to air dry. Conflicting information from the Health Department and the Dietary Manager's preference for air drying, as per the manufacturer's recommendation for the sanitizing solution, contributed to this issue. This practice posed potential cross-contamination and bacteria contamination risks for residents receiving an oral diet.
The facility experienced ice accumulation in the walk-in freezer, leading to ice build-up on food storage shelves and food products. Observations revealed significant ice on various food items, including a clear, plastic, resealable bag and an open box of hushpuppies. The Dietary Manager confirmed the ice build-up and had not noticed it previously.
The facility failed to accurately code an annual MDS assessment for a resident with a PASRR Level II assessment. Despite documentation and a provided list indicating the assessment, it was not marked on the MDS. The issue arose during the MDS Coordinator's leave, with part-time staff filling in.
The facility failed to follow care plans for three residents, including not creating a nutrition care plan, not adhering to a physician's order for oxygen therapy, and not updating a care plan to include a resident's refusal to wear a hand splint. These deficiencies were confirmed by the Director of Health Services and the Regional Consultant.
The facility failed to follow an OT Restorative Nursing Program recommendation for orthotic application for two residents, leading to a potential progression of contractures. Observations and interviews revealed inconsistent application and documentation of hand splints, with staff unaware of the requirements and care plans not being followed.
A resident with dementia, hypoxia, and anxiety disorder was observed receiving oxygen at higher flow rates than prescribed. The Unit Manager confirmed the discrepancy, and the Director of Health Services acknowledged that the staff did not follow the physician's order or the resident's care plan.
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41%. One LPN crushed a metoprolol ER tablet against policy, and another LPN did not prime an insulin pen before administration. Both actions could lead to adverse medical complications for the residents involved.
Improper Air Drying of Dishware Post-Sanitization
Penalty
Summary
The facility failed to ensure proper air drying of dishware after sanitization, as required by professional standards and facility policy. During an observation, a dietary cook was seen drying food processor equipment with a paper towel instead of allowing it to air dry completely. Interviews with the dietary cook and the Dietary Manager revealed conflicting information from the Health Department regarding the use of paper towels for drying dishware, with the DM preferring air drying as per the manufacturer's recommendation for the sanitizing solution used. This deficiency in dishware air drying procedures had the potential to impact the majority of residents receiving an oral diet at the facility. The use of a potent disinfectant solution in the three-compartment sink, combined with improper drying practices, could lead to cross-contamination and bacteria contamination risks for the residents. The facility's failure to adhere to the recommended air drying process outlined in their policy and the manufacturer's specifications for the sanitizing solution highlights a gap in ensuring food safety and infection control measures in the dietary department.
Ice Build-Up in Walk-In Freezer Affects Food Storage
Penalty
Summary
The facility failed to properly maintain the walk-in freezer, leading to ice build-up on food storage shelves and food products. Observations on 5/3/2024 and 5/5/2024 revealed significant ice accumulation on various food items, including a clear, plastic, resealable bag and an open box of hushpuppies. The Dietary Manager confirmed the ice build-up and admitted to not noticing it previously.
Failure to Accurately Code PASRR Level II Assessment on MDS
Penalty
Summary
The facility failed to accurately code an annual Minimum Data Set (MDS) assessment for a resident (R2) who had a Pre-Admission Screening and Resident Review (PASRR) Level II assessment. The facility's policy mandates that each MDS should reflect the acuity and medical status of each resident. However, a review of R2's annual MDS assessment revealed that the PASRR Level II assessment was not marked, despite documentation in the electronic medical record (EMR) and a facility-provided list indicating that R2 had undergone such an assessment. This discrepancy was confirmed by the Senior Nurse Consultant, who noted that the current MDS Coordinator was on leave and part-time staff were filling in to complete the assessments. The Social Service Director (SSD) stated that she provided the MDS Coordinator with a list of residents who had completed PASRR Level II assessments and updated the list as necessary. Despite this, the PASRR Level II assessment for R2 was not captured in the annual MDS assessment. The Senior Nurse Consultant admitted uncertainty about the process used by the MDS Coordinator to identify and code residents with PASRR Level II assessments, indicating a gap in the facility's procedures for ensuring accurate MDS coding during the coordinator's absence.
Failure to Follow Care Plans for Nutrition, Oxygen Therapy, and Hand Splint
Penalty
Summary
The facility failed to follow the care plan for three residents, leading to deficiencies in their care. For Resident 14, the facility did not create a care plan for nutrition services despite a physician's order for a regular, no added salt diet and a registered dietician's note indicating poor appetite and weight loss. This oversight was confirmed by the Director of Health Services and the Regional Consultant during the survey. For Resident 24, the facility did not follow the physician's order for oxygen therapy, as the oxygen was set at the wrong liter flow. This was confirmed by the Director of Health Services, who acknowledged that the staff did not adhere to the care plan or the physician's order. For Resident 30, the facility failed to update the care plan to include the resident's refusal to wear a hand splint, despite having a care plan that required the use of a hand orthotic from 7:00 am to 7:00 pm. The Director of Health Services confirmed that the care plan did not address the resident's refusal and that staff were not following the existing care plan. These deficiencies indicate a failure to provide necessary care services as outlined in the residents' care plans.
Failure to Follow Restorative Nursing Program for Orthotic Application
Penalty
Summary
The facility failed to follow an Occupational Therapy (OT) Restorative Nursing Program (RNP) recommendation for orthotic application for two residents, leading to a potential progression of contractures. Resident 1 (R1) was admitted with diagnoses including cerebrovascular disease, generalized muscle weakness, and contractures in both hands. Despite recommendations for orthotic use to maintain skin and joint integrity, there was no documentation or order in the electronic health record (EHR) for contracture management after R1 was discharged from skilled therapy services. Observations revealed that R1's orthotic device was not applied consistently, and interviews with staff confirmed that the splints were not being applied daily as required. The Director of Health Services (DHS) acknowledged the oversight and admitted to not verifying the implementation of the restorative plan of care in the EHR. Resident 30 (R30) had a diagnosis of dementia and a contracture in the right hand. The care plan required the application of a hand splint from 7:00 am to 7:00 pm, but observations and interviews indicated that the splint was not applied routinely. Staff were unaware of the requirement to apply the hand splint, and there were gaps in the documentation of its application. The DHS confirmed that the care plan was not followed and that there was confusion among staff regarding the documentation for the hand and leg braces. This confusion led to inconsistent application and documentation of the hand splint for R30. Interviews with various staff members, including Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs), revealed a lack of awareness and training regarding the application of the hand splints. Some staff members were only aware of the leg brace and not the hand splint, while others did not document refusals of care in the EHR. The Therapy Manager also admitted to not checking the records to ensure that the restorative orders were followed. This lack of communication and oversight contributed to the failure to provide the necessary orthotic care for both residents, potentially leading to the progression of their contractures.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure oxygen was administered in accordance with the physician's order for a resident receiving oxygen therapy. The resident, who had diagnoses of unspecified dementia, hypoxia, and anxiety disorder, was observed multiple times receiving oxygen at higher flow rates than prescribed. Specifically, the resident's oxygen concentrator was set at four liters per minute (LPM) and three LPM instead of the ordered two LPM. The Unit Manager confirmed the discrepancy but could not provide an explanation for the incorrect settings. The Director of Health Services was unaware of the issue and confirmed that the licensed nursing staff did not follow the physician's order or the resident's care plan. The expectation was for staff to adhere to the physician's order, but this was not done in this case. The deficiency was identified through observations, staff and resident interviews, and record reviews, highlighting a failure in administering oxygen therapy as prescribed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a medication error rate of 7.41%. One incident involved a resident with diagnoses including hypertensive heart, chronic kidney disease with heart failure, and paroxysmal atrial fibrillation. The Licensed Practical Nurse (LPN) crushed a metoprolol succinate 25 mg extended-release (ER) tablet, which was on the facility's Do Not Crush list, and administered it to the resident. The LPN admitted to normally crushing the medications at the resident's request and did not check the Do Not Crush list before doing so. The Director of Health Services (DHS) confirmed that the nurse should have contacted the pharmacy or physician for an alternative form of the medication instead of crushing it, as this could lead to adverse medical complications for the resident. Another incident involved a resident with type 2 diabetes mellitus. The LPN failed to prime the Novolog Flex Pen insulin by dialing up 2 units before administering the ordered dose of 8 units. The LPN was unaware of the need to prime the pen, which could result in the resident receiving less than the ordered amount of insulin. The DHS confirmed that the nurse should have followed the manufacturer's guidelines and facility policy when administering insulin, as failing to prime the pen could cause medical complications for the resident. Both incidents highlight the facility's failure to adhere to its own medication administration policies and procedures, leading to a medication error rate above the acceptable threshold. The DHS acknowledged the lapses in following the Do Not Crush list and insulin administration guidelines, and indicated that education on these procedures would be provided to the nurses immediately.
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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 Forsyth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Forsyth | 7.4 mi | ★★★★★ | 7 | 0 |
| Westbury Center Of Jackson For Nursing And Healing | 10.4 mi | ★★★★★ | 2 | 0 |
| Heritage Inn Of Barnesville Health And Rehab | 12.7 mi | ★★★★★ | 0 | 0 |
| Bolingreen Health And Rehabilitation | 18.3 mi | ★★★★★ | 2 | 0 |
| Spalding Post Acute Llc | 18.9 mi | ★★★★★ | 11 | 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.