Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure residents has the right to be informed
of, and participate in, their treatment for one (Resident #17) of four residents reviewed for resident rights.
Residents Affected - Few
-The facility failed to ensure Resident #17'ss wishes to discontinue use of Estradiol (estrogen).
This failure could place residents at risk of not being part of the decision-making process for their care.
The findings included:
Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE].
Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain
cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory,
thinking and social abilities severely enough to interfere with your daily life), muscle wasting (loss of muscle
leading to its shrinking and weakening) and atrophy (decrease in size or wasting away of a body part or
tissue arrested development), lack of coordination, type 2 diabetes mellitus (a condition results from
insufficient production of insulin, causing high blood sugar), polyneuropathy (damage to multiple peripheral
nerves), hypertension (high pressure in the arteries), hemiplegia (paralysis of one side of the body) and
hemiparesis (is weakness on one side of the body) of the right side, dysphagia (difficulty in swallowing food
or liquid difficulty in swallowing food or liquid), and chronic kidney disease (a condition where the kidneys
lose their ability to filter blood and remove wastes and fluids).
Record review of Resident #17's quarterly MDS dated [DATE] with an ARD of 5/12/2023 revealed a BIMS
of 11 indicating minimal cognitive impairment. The MDS revealed he had no indications of psychosis,
behaviors affecting others, or wandering or elopement behaviors, and he rejected care between one and
three days in the seven days prior to the assessment. The MDS documented Resident #17 required
extensive assistance from one or more caregivers with bed mobility, transfers, locomotion, dressing,
personal hygiene, and toileting, and minimal assistance with set-up for eating. The MDS noted he was
always incontinent of bladder and bowel, but he was not on a toileting program. The MDS revealed he was
at risk of developing pressure ulcers or injuries, had two venous (typically shallow with irregular sloping
edges) and/or arterial (deep and has a 'punched out' appearance) ulcers (an open sore on an external or
internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal) of the
feet, and was receiving treatment for the injuries. The MDS documented Resident #17 received
anticoagulant and diuretic medication seven days of the seven days prior to the assessment. The MDS
noted he received no therapeutic services.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
455715
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0552
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Record review of the Resident #17's care plan, updated 3/7/2023, revealed a focus on his propensity to
curse at staff and make inappropriate comments to female staff members with interventions including
anticipation of his needs, positive interactions, discussion of inappropriate behaviors.
Record review of Resident #17's medication record revealed he was prescribed Estradiol (a female
hormone that regulates many functions in the body, such as reproduction, mood, and bone health) 1mg
tablet, one tablet daily, for inappropriate sexual behaviors. The prescription was ordered on 4/11/2023 and
initiated on 4/12/2023.
Record review of Resident #17's medication record revealed prescriptions for Estradiol 1mg tablet one time
daily for inappropriate sexual behaviors.
Record review of a nurse's note dated 4/11/2023 documented Resident #17 was being sexually
inappropriate with CNA's during bed bath today. Record review of a nurse's noted dated 4/11/2023 revealed
Resident #17 was prescribed Estradiol 1mg for inappropriate sexual behaviors.
Record review of a nurse's note dated 5/24/2023 created by the DON revealed Resident #17 refused to
sign a consent for Estradiol and informed the nurse he did not want to take it.
Record review of Resident #17's May 2023 MAR revealed he had been administered Estradiol 5/25/2023
through 5/31/2023 daily at 9:00 AM.
Record review of Resident #17's June 2023 MAR revealed he had been administered Estradiol 6/1/2023
through 6/8/2023 daily at 9:00 AM.
Observation on 6/6/2023 at 9:09 AM of Resident #17 revealed he was lying in his bed watching television.
Resident #17 appeared clean and appropriately groomed.
Interview on 6/7/2023 at 8:02 AM with Resident #17, he said he did not know the names of all the
medications he took. Resident #17 said he did not know if he was prescribed, administered, or took
Estradiol. Resident #17 said he did not know what Estradiol would treat.
Interview on 6/8/2023 at 12:18 PM with Resident #17, he said he had spoken with the Admin regarding his
Estradiol on 6/8/2023. Resident #17 said he wanted to take the estradiol because it calmed him down.
Resident #17 said he had not known he was taking it in the past. Resident #17 said the facility and staff had
not informed him of the medications he takes. Resident #17 said the staff would administer the medication
and tell him to take it without explaining what he was taking.
Interview on 6/7/2023 at 1:14 PM with CNA A, she said she had been employed as a CNA since December
of 2022. CNA A said her primary duties as a CNA were to assist residents with showers, other ADL's,
weigh the residents, and assist the residents with what they needed. CNA A said Resident #17 did not
appear to have a problem with her. CNA A said Resident #17 preferred specific CNA's and nurses. CNA A
said Resident #17 routinely refused care. CNA A said Resident #17 had acted inappropriately with her.
CNA A said he had made inappropriate jokes and had attempted to touch her bottom. CNA A said she had
informed the facility management about her concerns. CNA A said Resident #17's inappropriate behaviors
had decreased since she informed management of the issues.
Interview on 6/8/20 at 8:14 AM with The MDS, she said Resident #17's Estradiol was not on his care plan.
The MDS said it was not on his care plan because he had come to the facility with the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0552
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
prescription. The MDS said she thought the Estradiol was controlling Resident #17's inappropriate sexual
behaviors and that was why she had not included it as an intervention on the care plan. The MDS reviewed
the EHR and said the Estradiol was prescribed on 4/11/2023. The MDS said the Estradiol should have
been included on the care plan as an intervention for the Resident #17's focus on inappropriate sexual
behaviors. The MDS said she was unsure if Resident #17 had received any psychiatric or social work
intervention to address the inappropriate sexual behaviors.
Telephone interview on 6/8/2023 with Resident #17's PCP at 10:34 AM, he said he thought he was aware
Resident #17 was prescribed Estradiol. Resident #17's PCP said Estradiol was not a common medication,
but it may have been used for sexually inappropriate behaviors. Resident #17's PCP said if Resident #17
was his own responsible party, he could choose to refuse and/or discontinue the medication.
Telephone interview on 6/8/2023 with Resident #17's NP at 10:42 AM, she said Resident #17 was
prescribed Estradiol for inappropriate sexual behaviors. Resident #17's NP said she had prescribed
Estradiol in the past to residents with inappropriate sexual behaviors and it had decreased the behaviors.
Resident #17's NP said the estradiol could decrease Resident #17 grabbing behaviors. Resident #17's NP
said the estradiol helps the nurses to work with Resident #17 and would stop him from grabbing their lady
parts. Resident #17's NP said she had not been informed Resident #17 had refused to take the Estradiol.
Resident #17's NP said he could refuse his medication if he was his own responsible party.
Interview on 6/8/2023 at 11:17 AM with the DON, she said if a resident had inappropriate verbal behaviors,
she would address the concern and move on. She said if the behaviors were physical, she would move the
resident's hand, speak to the resident, and move on. The DON said if the behaviors continued or became
invasive the facility progress to medication reviews, possible referral to an inpatient geriatric psychiatric
hospital, or obtaining physician's orders for medication to address the behaviors. The DON said it was not
her decision to determine if Resident #17 should have begun the medication after what was documented
as a one-time occurrence, it was the prescribers. The DON said she did speak to Resident #17, on
5/24/2023, where he expressed a desire to discontinue his use of Estradiol. The DON said she did not
discuss the discontinuation of the orders with the physician. The DON said at that time there was another
interim DON who would have contacted the physician. The DON said if Resident #17 verbally refused to
take the Estradiol a discontinuation of orders should have been obtained from the physician.
Interview on 6/8/2023 at 12:05 PM with the Admin, he said he had spoken to Resident #17 regarding his
prescription for Estradiol. The Admin said he had chosen to continue taking the medication.
Record review of the facility's Medication Administration policy date 10/1/2019 read in part medications are
administered as prescribed in accordance with good nursing principles and practices ., .the patient has the
right to know exactly what they are taking, people taking medication have the right to refuse medications .,
.residents may actively refuse medications ., and medication refusal must be reported to the prescriber or
mid-level practitioner after every vital medication is refused and after every 3rd dose of a nonvital
medication and there must be documentation of prescriber notification of such .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure each resident's drug regimen was free from
unnecessary drugs for 1 of 6 residents (Resident#17) reviewed for unnecessary drugs.
Residents Affected - Few
The facility failed to ensure Estradiol (a female hormone that regulates many functions in the body, such as
reproduction, mood, and bone health) was appropriate for Resident #17. Estradiol was prescribed for one
documented incident of sexualized behavior which is an off-label use.
This failure could place residents receiving medications at risk of a possible inappropriate drug use or
adverse drug reaction. hospitalization.
Findings included:
Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE].
Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain
cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory,
thinking and social abilities severely enough to interfere with your daily life), muscle wasting (loss of muscle
leading to its shrinking and weakening) and atrophy (decrease in size or wasting away of a body part or
tissue arrested development), lack of coordination, type 2 diabetes mellitus (a condition results from
insufficient production of insulin, causing high blood sugar), polyneuropathy (damage to multiple peripheral
nerves), hypertension (high pressure in the arteries), hemiplegia (paralysis of one side of the body) and
hemiparesis (is weakness on one side of the body) of the right side, dysphagia (difficulty in swallowing food
or liquid difficulty in swallowing food or liquid), and chronic kidney disease (a condition where the kidneys
lose their ability to filter blood and remove wastes and fluids).
Record review of Resident #17's quarterly MDS dated [DATE] with an ARD of 5/12/2023 revealed a BIMS
of 11 indicating minimal cognitive impairment. The MDS revealed he had no indications of psychosis,
behaviors affecting others, or wandering or elopement behaviors, and he rejected care between one and
three days in the seven days prior to the assessment. The MDS documented Resident #17 required
extensive assistance from one or more caregivers with bed mobility, transfers, locomotion, dressing,
personal hygiene, and toileting, and minimal assistance with set-up for eating. The MDS noted he was
always incontinent of bladder and bowel, but he was not on a toileting program. The MDS revealed he was
at risk of developing pressure ulcers or injuries, had two venous (typically shallow with irregular sloping
edges) and/or arterial (deep and has a 'punched out' appearance) ulcers (an open sore on an external or
internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal) of the
feet, and was receiving treatment for the injuries. The MDS documented Resident #17 received
anticoagulant and diuretic medication seven days of the seven days prior to the assessment. The MDS
noted he received no therapeutic services.
Record review of the Resident #17's care plan, updated 3/7/2023, revealed a focus on his propensity to
curse at staff and make inappropriate comments to female staff members with interventions including
anticipation of his needs, positive interactions, discussion of inappropriate behaviors.
Record review of Resident #17's medication record revealed he was prescribed Estradiol (a female
hormone that regulates many functions in the body, such as reproduction, mood, and bone health) 1mg
tablet, one tablet daily, for inappropriate sexual behaviors. The prescription was ordered on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
4/11/2023 and initiated on 4/12/2023.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #17's medication record revealed prescriptions for Estradiol 1mg tablet one time
daily for inappropriate sexual behaviors.
Residents Affected - Few
Record review of a nurse's note dated 4/11/2023 documented Resident #17 was being sexually
inappropriate with CNA's during bed bath today. Record review of a nurse's noted dated 4/11/2023 revealed
Resident #17 was prescribed Estradiol 1mg for inappropriate sexual behaviors.
Observation on 6/6/2023 at 9:09 AM of Resident #17 revealed he was lying in his bed watching television.
Resident #17 appeared clean and appropriately groomed.
Interview on 6/8/2023 at 12:18 PM with Resident #17, he said he had spoken with the Admin regarding his
Estradiol on 6/8/2023. Resident #17 said he wanted to take the estradiol because it calmed him down.
Resident #17 said he had not known he was taking it in the past. Resident #17 said the facility and staff had
not informed him of the medications he takes. Resident #17 said the staff would administer the medication
and tell him to take it without explaining what he was taking. Resident #17 did not recall any psychiatric
care services.
Interview on 6/7/2023 at 1:14 PM with CNA A, she said she had been employed as a CNA since December
of 2022. CNA A said her primary duties as a CNA were to assist residents with showers, other ADL's,
weigh the residents, and assist the residents with what they needed. CNA A said Resident #17 did not
appear to have a problem with her. CNA A said Resident #17 preferred specific CNA's and nurses. CNA A
said Resident #17 routinely refused care. CNA A said Resident #17 had acted inappropriately with her.
CNA A said he had made inappropriate jokes and had attempted to touch her bottom. CNA A said she had
informed the facility management about her concerns. CNA A said Resident #17's inappropriate behaviors
had decreased since she informed management of the issues.
Interview on 6/8/20 at 8:14 AM with the MDS, she said the Estradiol should have been included on the care
plan as an intervention for the Resident #17's focus on inappropriate sexual behaviors.
Telephone interview on 6/8/2023 with Resident #17's PCP at 10:34 AM, he said he thought he was aware
Resident #17 was prescribed Estradiol. Resident #17's PCP said Estradiol was not a common medication,
but it may have been used for sexually inappropriate behaviors.
Telephone interview with on 6/28/2023 Resident #17's NP at 10:42 AM, she said Resident #17 was
prescribed Estradiol for inappropriate sexual behaviors. Resident #17's NP said she had prescribed
Estradiol in the past to residents with inappropriate sexual behaviors and it had decreased the behaviors.
Resident #17's NP said the estradiol could decrease Resident #17 grabbing behaviors. Resident #17's NP
said the estradiol helps the nurses to work with Resident #17 and would stop him from grabbing their lady
parts.
Interview on 6/8/2023 at 11:17 AM with the DON, she said if a resident had inappropriate verbal behaviors,
she would address the concern and move on. She said if the behaviors were physical, she would move the
resident's hand, speak to the resident, and move on. The DON said if the behaviors continued or became
invasive the facility progress to medication reviews, possible referral to an inpatient geriatric psychiatric
hospital, or obtaining physician's orders for medication to address the behaviors. The DON said it was not
her decision to determine if Resident #17 should have begun the medication after what was documented
as a one-time occurrence, it was the prescribers. The DON said she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
did not know Resident #17's history with the prescriber, but in general the least restrictive approach should
be utilized for inappropriate behaviors, and medication may not be the least restrictive.
Record review of the FDA's medication label for estradiol revealed it's typical uses included treatment of
moderate to severe vasomotor symptoms associated with the menopause, treatment of moderate to severe
symptoms of vulvar and vaginal atrophy associated with the menopause, treatment of hypoestrogenism
due to hypogonadism, castration or primary ovarian failure, treatment of breast cancer (for palliation only) in
appropriately selected women and men with metastatic disease, treatment of advanced
androgen-dependent carcinoma of the prostate (for palliation only), and prevention of osteoporosis. The
label documented estradiol was contraindicated for undiagnosed abnormal genital bleeding, known,
suspected, or history of cancer of the breast, known or suspected estrogen-dependent neoplasia, active
deep vein thrombosis, pulmonary embolism or history of these conditions, active or recent (e.g., within the
past year) arterial thromboembolic disease (e.g., stroke, myocardial infarction), and liver dysfunction or
disease. The label further documented estradiol should not be used in patients with known hypersensitivity
to its ingredients, and estradiol 2 mg, contain FD&C Yellow No. 5 (tartrazine) which may cause allergic-type
reactions (including bronchial asthma) in certain susceptible individuals.
Record review of the FDA's boxed warnings for Estradiol revealed estrogen therapy has been associated
with an increased risk of cardiovascular events such as myocardial infarction and stroke, as well as venous
thrombosis and pulmonary embolism, and should any of these occur or be suspected, estrogens should be
discontinued immediately. The boxed warnings documented an increase in the risk of gallbladder disease
requiring surgery in postmenopausal women receiving estrogens had been reported. The boxed warning
further revealed estrogen administration may lead to severe hypercalcemia in patients with breast cancer
and bone metastases. Per the boxed warnings retinal vascular thrombosis had been reported in patients
receiving estrogens.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals
were stored securely for three (Nurse Cart 2B Hall, Med Aide Cart 1A Hall, Nurse cart 2A Hall) of four
medication carts reviewed for storage of medications.
Nurse Cart 2B Hall, Med Aide Cart 1A Hall and Nurse cart 2A Hall had punctured protective seals on the
back of multiple narcotic medication blister pill cards.
This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse
reactions to medications and drug diversion.
Findings included:
Nurse Cart 2B Hall:
Observation on 05/31/2023 at 10:00am revealed the narcotic storage of Lorazepam 0.5mg tablets #5 and
#6 of 9 tablets had torn protective seals. A second blister card of Lorazepam 0.5mg, tablet #3 of 4 tablets
had a torn protective seal. A third blister card of Lorazepam, tablet #6 of 30 tablets had a torn protective
seal.
In an interview on 05/31/2023 at 10:00AM, LVN E stated if the resident needed a dose of Lorazepam, he
would use the tablets with the broken seal first. LVN E stated if the seal was broken there would be an
infection control issue, or someone could remove the pills. LVN E stated he will waste the tablets with
another nurse.
Med Aide Cart 1A Hall:
Observation on 05/31/2023 at 10:43AM revealed the narcotic storage of Lorazepam 0.5mg, tablet #10 of 10
tablets had a torn seal that was taped over with paper tape.
In an interview with RN B and DON on 05/31/2023 at 10:43AM, RN B stated the Lorazepam tablet may fall
out, get lost and the resident will not have any pills available when needed. RN B stated it should not have
been taped, it should be wasted. The DON stated it should not have tape and will be wasted.
Nurse Med Cart 2A Hall:
Observation on 06/01/2023 at 12:45PM revealed the narcotic storage of Tramadol 50mg (1/2tabs), tablets
#2, #3, #5 of 6 tablets had torn protective seals. A blister card of Lorazepam 0.5mg, had 16 tablets; blister
seal #3 was torn, #15 had a puncture, #6 and #8 were torn and taped over with paper tape. A second
blister card of Lorazepam 0.5mg tabs had 14 tablets and seal #8 was torn. A third Lorazepam 0.5mg blister
card had 34 tablets and blister seal #6 was torn.
In an interview on 06/01/2023 at 12:45PM, LVN D stated it was not correct to tape up the seals that were
broken. LVN D stated the risk would be infection, loss of the drug, depletion of the resident's supply and the
tablet may not be the same that was originally in the package. LVN D stated she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
would notify the ADON, waste the meds with another nurse and place reorders.
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 06/01/2023 at 12:50PM, LVN E said all nurses in charge of medication carts were
responsible for checking the integrity of blister seals on all packaging.
Residents Affected - Few
In an interview on 06/01/2023 at 4:40PM, the Administrator stated she expected the nurses to be
responsible for checking the integrity of the packaging since they are the ones who count it daily. The
Administrator stated she expected nurses to waste the meds if the seals are broken as the tablets could fall
out and picked up by anyone. The Administrator then stated, I don't know, I would probably tape it if the seal
was broken only slightly then label it, do not use, or waste it later.
Record review of the facility policy for storage of medications, revised April 2007 read in part: Policy
Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy
Interpretation and Implementation: 1. Drugs and biologicals shall be stored in the packaging, containers or
other dispensing systems in which they are received .2. The nursing staff shall be responsible for
maintaining medication storage AND preparation areas in a clean, safe and sanitary manner. 3. Drug
containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy
for proper labeling before storing
Record review of the facility policy for Controlled Substances, revised December 2012 read in part: Policy
Statement: The facility shall comply with all laws, regulations, and other requirements related to handling,
storage, disposal, and documentation of Schedule II and other controlled substances
Record review of the undated facility policy for Drug Diversion revealed in part: .Goal, to support the health
and safety of its employees, patients and visitors. Policy: Drug diversion (theft) is prohibited. Suspected
drug diversion will be investigated .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to maintain an infection prevention and control
program designed to provide a safe, sanitary, and comfortable environment and to help prevent the
development and transmission of communicable diseases and infections for one of 8 residents reviewed for
infection control (Resident #30).
Residents Affected - Few
The facility failed to ensure the needle used on Resident #30, remained sterile during the procedure for
intramuscular injection of the antibiotic Ceftriaxone.
This failure could place residents at risk of infection, decline in health and hospitalization.
Findings included:
Record review of Resident #30's face sheet revealed a [AGE] year-old male admitted to the facility
02/21/2021 and initially admitted on [DATE]. His diagnoses included atrial fibrillation (abnormal heart
rhythm), Parkinson's disease, muscle wasting, pain in joints, age related debility, behavioral and emotional
disorder, depression, non-cancerous tumor of the salivary gland, HTN and contractures of the hips and of
the knees.
Record review of Resident #30's quarterly MDS dated [DATE] revealed he had short term and long term
memory problem. He had moderately impaired cognitive skills for daily decision making. He required
extensive assistance with ADLs and was always incontinent of bowel and bladder. Further review revealed
he was receiving antibiotics and IV medications.
Record review of Resident #30's undated care plan revealed the resident had an infection of swollen lymph
nodes to the right cheek/jaw area, date initiated was 06/05/2023. The goal was for resident to be free of
complications related to infection. Interventions included nurses to administer antibiotics as per MD orders.
Record review of Resident #30's active physician orders revealed an order to start Ceftriaxone sodium
solution reconstituted 1gm, inject 1 gm IM every 24 hours for swollen lymph nodes with fever on start date
06/07/2023 and end date of 06/10/2023.
Observation and interview on 06/07/2023 at 9:10AM, RN A prepared Ceftriaxone 1gm vial. RN A
reconstituted the Ceftriaxone 1gm by adding 2.1 ml of Lidocaine 1%. RN A put on clean gloves, cleansed
the stopper on the Ceftriaxone vial with an alcohol prep pad, removed the cap of the needle, set the cap
down on the med cart, withdrew the liquid using a 3ml syringe and 22 g needle. RN A walked to Resident
#30's bedside, explained the procedure to Resident #30, opened a small alcohol prep pad, placed the pad
on top of the outer package of the prep pad and placed the syringe with exposed needle on top of the
alcohol pad. RN A removed gloves and donned clean gloves then disinfected Resident #30's dorsogluteal
site (left hip area) with an alcohol prep pad. RN A picked up the syringe with needle and wiped the needle
using the alcohol prep pad. RN A injected the content of the syringe and needle into Resident #30's
dorsogluteal site, swabbed the site with a new alcohol pad and disposed of the syringe with the needle in a
sharps container. RN A stated he did not recap the needle d/t the potential of a needle stick. RN A stated
he wiped the needle with alcohol to clean and disinfect it. RN A was asked if wiping the needle with alcohol
was facility policy. RN A stated it was the way he learned how to do injections.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Rehabilitation and Nursing Center
120 State Loop 92
LA Grange, TX 78945
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 06/07/2023 at 4:30PM, the DON stated after drawing up the injectable medication she
expected the nurse to cover the needle with the cap in a way to prevent a needle stick. The DON stated the
cap did not necessarily need to be tightly secured. The DON stated it was not policy to wipe down the
needle. The DON stated the risk would be an infection control issue and potential needle stick. The DON
stated she would monitor Resident #30's injection site for infection keeping in mind the Ceftriaxone may
cause redness by itself.
Interview on 06/08/2023 at 8:30AM RN A stated he had been working at the facility about 1.5 years now
and had an inservice regarding administration of medication about one week ago.
Interview on 06/08/2023 at 8:35AM, the DON stated the DON or the corporate nurse was responsible to
conduct nursing staff inservices for medication administration.
Interview on 06/08/2023 at 10:10AM, the DON stated the records for Nursing Administration of Medications
inservices were completed through the online learning courses provided by the facility. The DON stated RN
A had signed an inservice on 2/6/2023.
Record review of the online learning transcript included RN A's completion of the one-hour course for
Medication Administration in Acute Care on 2/06/2023, with a final score of 100.
Record review of the facility policy and procedure manual, section: Medication Administration, Injectable
Administration revised on 10/01/2009 read in part: Policy: to administer medications via subcutaneous,
intradermal and intramuscular routes in a safe, accurate and effective manner. Equipment Required .2.
Sterile syringe capable of holding the medication volume. 3. Sterile safety needle .Procedure .Sites for
Administration: .Intramuscular .withdraw the medication; create air lock. Do not recap needle, remove air
bubbles .Sanitize hands with approved sanitizer .put on gloves .prepare skin for injection, remove air from
syringe and insert the needle .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455715
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the June 8, 2023 survey of Monument Rehabilitation and Nursing Center?
This was a inspection survey of Monument Rehabilitation and Nursing Center on June 8, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Monument Rehabilitation and Nursing Center on June 8, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.