Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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-union Pointe during CMS and state inspections, most recent first.
Several residents with chronic conditions did not receive their scheduled medications when only two nurses remained on duty overnight, and neither accepted responsibility for administering medications to one hall after another nurse left. The interim DON was not informed of the staffing shortage, and the Administrator was notified but believed staffing was sufficient. The Medical Director was informed, and all affected residents were assessed with no negative outcomes.
The facility did not provide enough nursing staff to administer scheduled medications as ordered, resulting in significant medication errors for multiple residents on one unit. Despite attempts by staff to find coverage, there were times when no nurse was available to pass medications, leading to missed doses and failure to meet residents' needs.
Seventeen residents with complex medical needs did not receive their scheduled medications when no nurse was assigned to administer them on a specific hall. The missed doses included critical medications such as anticoagulants, antihypertensives, insulin, antipsychotics, and pain relievers. The deficiency resulted from inadequate nursing coverage during an overnight shift, with remaining nurses unwilling to assume additional responsibilities and the interim DON not being contacted about the staffing shortage. The administrator was informed and attempted to address the staffing issue, but the medications were ultimately not administered as ordered.
The facility did not conduct or document required quarterly care conferences for several residents, including those who were cognitively intact and one who was severely cognitively impaired. Residents and their representatives reported not being invited or included in care conferences, and staff interviews revealed confusion over responsibility for scheduling these meetings. An audit found that many residents lacked documented care plan meetings, reflecting a breakdown in the care planning process.
A resident with a history of stroke and dementia was ordered IV antibiotics after refusing oral medications. When the resident was combative and the midline IV could not be inserted, nursing staff notified the resident's representative but failed to promptly inform the physician or NP, resulting in a delay in physician notification about the unsuccessful IV attempt.
Two cognitively impaired residents in an LTC facility were not protected from sexual abuse. Staff observed inappropriate sexual contact between a male and female resident, both unable to consent. Despite witnessing the incident, staff did not immediately separate the residents, and the female resident returned to the male's room shortly after. The facility failed to implement immediate protective measures, contributing to the deficiency.
A facility failed to implement its abuse policy when two cognitively impaired residents were found engaged in non-consensual sexual activity. Staff did not immediately separate the residents or report the incident to authorities. The facility's Director of Health Services and Administrator were informed but did not take necessary actions to report or investigate the incident, leading to an Immediate Jeopardy finding.
Failure to Administer Scheduled Medications Due to Staffing Issues
Penalty
Summary
The facility failed to administer scheduled medications as ordered by physicians for seven residents on the 500 hall. These residents had various diagnoses, including major depressive disorder, generalized anxiety disorder, Alzheimer's disease, and chronic pain, and were prescribed medications such as Lorazepam, Mirtazapine, Gabapentin, Zoloft, Donepezil, and Trazodone. Review of the Medication Administration Records (MAR) for December 2024 showed that on 12/7/2024, these residents did not receive their prescribed medications at the scheduled times. The deficiency occurred due to staffing issues during the 7:00 PM to 7:00 AM shift. After 10:30 PM, only two nurses remained in the facility, and neither was willing to take responsibility for administering medications on the 500 hall after another nurse left at 11:00 PM. One nurse communicated to the Administrator that she did not feel safe taking on the additional assignment, and as a result, neither of the two remaining nurses administered medications to the 500 hall residents. The interim DON was not contacted about the staffing shortage and was unaware of the situation at the time. Interviews with staff and the Medical Director confirmed that the residents did not receive their scheduled medications due to the lack of a nurse assigned to the 500 hall. The Administrator was notified of the staffing shortage and attempted to contact additional nurses but ultimately determined there was sufficient staff present. The Medical Director was informed of the missed medication administration, and all affected residents were assessed, with no negative outcomes reported.
Insufficient Nursing Staff Resulting in Missed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically on the 500 hall/unit, resulting in the inability to administer medications as ordered for 17 out of 24 residents reviewed. Record review and staff interviews revealed that when nurses called out, the procedure was to notify the Staffing Coordinator or Administrator. Despite attempts by the Staffing Coordinator to contact off-duty nurses and inform the Administrator and interim DON, there were instances where no additional nurses could be secured to cover the shift. As a result, scheduled medications were not administered as prescribed by physicians. Further interviews with the Unit Manager indicated that when short staffed, she would attempt to adjust the schedule or notify appropriate leadership. If unable to secure additional staff, the expectation was that the Unit Manager or Supervisor would take a medication cart to administer medications. However, on the dates in question, there was no nurse assigned to administer medications on the 500 hall, leading to significant medication errors for multiple residents. The deficiency was substantiated by cross-references to related tags regarding medication administration failures.
Significant Medication Errors Due to Lack of Nursing Coverage
Penalty
Summary
Seventeen residents on the 500 hall did not receive scheduled medications as ordered by their physicians due to a lack of nursing staff assigned to administer medications. The affected residents had a range of significant medical conditions, including atrial fibrillation, congestive heart failure, hypertension, diabetes mellitus, bipolar disorder, schizophrenia, Parkinson's disease, and chronic pain, among others. The missed medications included critical drugs such as anticoagulants, antihypertensives, insulin, antipsychotics, anticonvulsants, and pain relievers, as documented in the Medication Administration Records (MARs) for the specified dates. The deficiency occurred when, after 10:30 PM, only two nurses remained in the facility to cover all units, and neither nurse was willing to take responsibility for the 500 hall after another nurse left at 11:00 PM. As a result, no medications were administered to residents on the 500 hall during the overnight shift. Interviews with staff revealed that the nurses did not want to assume additional assignments, and the interim DON was not contacted about the staffing shortage. The administrator was informed of the staffing issue and attempted to contact additional nurses but ultimately determined that the remaining staff was sufficient. The Medical Director was notified of the incident and confirmed that residents did not receive their scheduled medications. The administrator and Medical Director both acknowledged the missed doses, and the Medical Director reviewed the situation to assess for any significant changes in resident status. The MARs and staff interviews confirmed that the medications were not administered as ordered, resulting in significant medication errors for the affected residents.
Failure to Conduct and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences with residents and their families, as required, for three residents reviewed. One resident, who was cognitively intact, had a care conference documented in January, but no subsequent conference was held as scheduled in April. The resident confirmed that it had been months since her last care conference. Another cognitively intact resident had a care conference upon admission in November, but no further conferences were documented or held as scheduled in February. This resident also reported not having another care conference since admission. A third resident, who was severely cognitively impaired, had no care conferences documented in the medical record. The resident's representative, who held Power of Attorney, reported not receiving any invitation to participate in a care conference. Staff interviews revealed confusion regarding responsibility for scheduling and conducting care conferences, with the former Social Worker stating she was unaware it was her duty and was unable to catch up once informed. The Administrator and Nurse Consultant confirmed that the Social Worker had been responsible for care conferences, but after her termination, a review of resident charts revealed that many care conferences had not been completed. An audit identified that a significant number of residents were missing documented quarterly care plan meetings, indicating a systemic failure to ensure resident and representative participation in the care planning process.
Failure to Notify Physician of Unsuccessful IV Insertion
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of an unsuccessful attempt to insert a midline intravenous (IV) line for a resident with a history of stroke and dementia. The resident, who was rarely or never understood, had a positive urine culture and possible pneumonia, and was ordered to receive IV antibiotics after refusing oral medications. The physician's order specified the insertion of a midline IV and administration of cefepime. However, the nursing note documented that the IV could not be inserted due to the resident's combative behavior, and only the resident's representative was notified. Nurse #3, who was present during the failed IV insertion, informed the Unit Manager (UM) but did not directly notify the on-call Nurse Practitioner (NP), assuming the UM would do so. The UM, in turn, did not notify the NP, believing it was Nurse #3's responsibility. As a result, the NP was not informed of the failed IV insertion until the following day. The delay in notification meant the NP was not immediately aware of the resident's inability to receive the ordered IV antibiotic treatment.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse, both of whom were severely cognitively impaired and unable to consent to sexual acts. On the day of the incident, staff members observed a female resident in a male resident's room, where inappropriate sexual contact was taking place. The male resident was lying on his back, naked from the waist down, while the female resident was on top of him with her pants and brief down at her ankles. The male resident was attempting to insert his penis into the female resident and was touching her private parts. Despite the presence of staff, the residents were not immediately separated, and the female resident was found in the male resident's room again shortly after the initial incident. The female resident had a history of dementia with psychosis and a cognitive communication deficit, requiring moderate assistance with transfers and using a wheelchair for mobility. Her care plan noted behaviors of attempting to touch others and resisting care. The male resident had a history of stroke and schizophrenia, was independent with transfers and toileting, and had verbal behaviors of threatening and fighting others. Despite these documented behaviors, the facility did not have adequate measures in place to prevent the incident from occurring. Staff members involved in the incident did not take immediate action to separate the residents upon discovering the situation. Instead, they called for additional staff assistance, which delayed the intervention. The facility's failure to implement one-to-one monitoring after the first incident allowed the female resident to return to the male resident's room, further compromising their safety. The facility's inaction and lack of immediate protective measures contributed to the deficiency in safeguarding the residents from sexual abuse.
Failure to Implement Abuse Policy and Protect Residents
Penalty
Summary
The facility failed to implement its abuse policy when two nurse aides observed two residents with severe cognitive impairments engaged in sexual activity, which they did not have the capacity to consent to. The staff did not immediately separate the residents to protect them from further abuse. Instead, they called for a nurse, who arrived and instructed the aides to separate the residents. Approximately 30 minutes later, one of the residents was found back in the other's room, attempting to remove his pants, indicating a lack of immediate protective measures. The facility also failed to report and investigate the incident as required by their abuse policy. There was no evidence that the residents were assessed for injuries or that the incident was reported to the state agency, Adult Protective Services, or law enforcement. The Director of Health Services and the Administrator were informed of the incident but did not take the necessary steps to report or investigate it thoroughly. The Administrator admitted to not considering the incident as sexual abuse due to the residents' cognitive impairments, which led to a failure in reporting. The deficiency was identified as Immediate Jeopardy, indicating a serious threat to the residents' health and safety. The facility's failure to implement protective measures and report the incident compromised the protection of the residents involved and potentially others. The lack of immediate intervention and reporting highlights a significant lapse in following the facility's abuse policy, which is crucial for ensuring resident safety and compliance with regulatory requirements.
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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
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jesse Helms Nursing Center | 3.9 mi | ★★★★★ | 3 | 0 |
| Monroe Rehabilitation Center | 4.2 mi | ★★★★★ | 4 | 0 |
| Rock Rest Nursing And Rehabilitation | 4.6 mi | ★★★★★ | 0 | 0 |
| Lake Park Nursing And Rehabilitation Center | 6.1 mi | ★★★★★ | 11 | 0 |
| Autumn Care Of Marshville | 10.1 mi | ★★★★★ | 5 | 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.