Inspection·July 2, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ex-maintenance director, 07/01/2025 revealed he was terminated when the door to the exterior in the activities room was left unlocked and Resident #1 was able to elope from the facility. He stated the door was unlocked and the alarm did not sound from what he heard from staff. He stated he worked earlier that day and was not at the facility when resident eloped. He stated he locked the door in the Activity room that leads to the courtyard and left the activity room from the door that led to the hallway. He stated another staff member must have left the door unlocked. He stated the resident was found at night in a grassy area next to the facility by a neighbor who then called EMS and the administrator of the facility. Ex-maintenance director stated the facility blamed him for this incident, but he was not working nor in charge of the resident.Interview with AD, 07/01/2025 revealed she was not working when Resident #1 eloped from the facility. AD just returned to work 2 days ago. AD stated the activity room door stayed locked when there was no activity. She stated the door leading to the courtyard, locked automatically from the outside. AD could not recall when the alar was installed on the activity room door.Interview with MA, 07/01/2025, revealed she was working the night Resident #1 eloped from the facility. She reported she administered Resident #1's nighttime medications at 8:30 PM. She stated she later heard Resident #1 had been found across the facility driveway in a grassy area outside the nearby neighborhood. She stated Resident #1 typically only walked when agitated so staff were surprised by the location where Resident #1 was found with her wheelchair beside her.Interview with LVN , 07/01/2025 revealed she last saw around 9:00 PM on hall 200 (which is not Resident #1's hallway). She stated Resident #1 was sundowning and disturbing two residents on the hallway. She redirected Resident #1 back to Resident #1's hallway at that time. She said Resident #1 was not exit seeking at that time. She stated the next thing she heard was that Resident #1 was outside thefacility and had exited through the activity room exterior door. She stated she did not hear any alarms sound to indicate a resident was outside. She stated she immediately grabbed resident roster to ensure everyone else was in the building. Interview with CNA A, 07/01/2025 revealed she worked with Resident #1 the night she eloped. CNA A stated she was working the night Resident #1 eloped from the facility. She last observed the resident around 9:00 p.m. in the hallway. CNA A reported that the resident was attempting to enter and exit multiple rooms, and she redirected the resident several times. She described the night as very busy, noting that she was assisting with bedtime routines for multiple residents and that there was an actively dying resident on the same hallway.According to CNA A, the resident did not allow staff to place her in bed that evening. She explained that it typically takes two staff members to assist the resident into bed when she is active. She stated that another CNA performed one round with her, then left. CNA A noted that the resident tends to be active at night and does not usually sleep through the night. She recalled that the resident often sat near the front door during nighttime hours. CNA A stated she provided her statement to the charge nurse on duty.Attempted interview with Resident #1's hallway CNA C, 07/01/2025, called twice and received no response.Interview with Administrator, 07/01/2025 revealed he was contacted by a neighbor of the facility on 4/8/25 that Resident #1 was outside the facility near the entrance to the neighbor's neighborhood. He spoke to LVN D, the charge nurse, over the phone and had her check the doors and alarms. He stated the only door unlocked and alarm not working was the activity room exterior door. He did not know why the alarm was malfunctioning on the door. He stated the maintenance director was held responsible for the door being unlocked and the alarm malfunctioning and was terminated as a result. He stated the resident was placed on 1:1 supervision immediately and then transferred to a secure facility. He stated he made rounds with all residents to ensure they felt safe. He stated new elopement assessments were completed on 4/9/25 on all residents with no other residents at high risk. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455715 If continuation sheet Page 2 of 4 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 07/02/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated they conducted in-services with all staff regarding elopements, securing doors/alarms, supervision, and abuse and neglect. Elopement drills were completed on all shifts on 4/9/25. He stated an ad hoc QAPI meeting was held on 4/9/25 with the medical director. He stated they also added a coded lock onto the activity room interior door so that a wandering resident would not be able to enter the room and use exit. He stated all doors, locks and alarms were evaluated on 4/9/25 and none were malfunctioning. Record Review of facility incident report dated 04/08/2025, revealed that Resident #1 eloped from the facility on that date. The facility ADM was notified by a neighbor of the facility that Resident #1 was observed outside in a grassy area left of the facility. Upon investigation, it was determined that the activity room door had been left unlocked, and the gate leading to the driveway area was open, which may have led to the resident's exit from the premises. Emergency Medical Services (EMS) assessed Resident #1 at the scene, after which the resident was transported to the hospital for further evaluation. The resident's physician and responsible party (RP) were notified on April 8, 2025. Following the incident and upon the resident's return to the facility, Resident #1 was placed on 1:1 supervision to ensure safety and prevent further incidents.Record Review of EMS report dated, 04/09/2025 reflected Resident #1 was found lying on the ground at 10:25 PM, 3 bystanders were with Resident #1 when EMS arrived. The report further stated, the bystanders stated they found Resident #1 lying in the grass, they noted Resident #1's wheelchair was found sitting upright a few feet away from resident and the resident possibly wandered outside the nursing home and then fell from her wheelchair into the grass. The resident was transferred to hospital.Attempted interview with Charge Nurse 07/02/2025, received no response.Interview with CNA B, 07/02/2025 revealed she was working the night Resident #1 eloped from the facility. She stated the administrator contacted the facility and spoke with the charge nurse. Upon noticing a concerning expression on the charge nurse's face during the call, CNA B stated she immediately exited through the front door. She observed EMS personnel near the facility and ran over to assist them in helping Resident #1 stand up. CNA B stated the resident was found on the ground in a grassy area, with her wheelchair positioned against a fence. She reported that she was unsure how the resident exited the facility. Although staff believe Resident #1 may have left through the activity room door, CNA B noted that the door is typically locked. She also stated that no door alarms sounded that night. CNA B recalled that Resident #1 was able to tell EMS her name and age. Interview with Resident #1 RP revealed Resident #1 was supervised with 1:1 staff prior to Resident #1 being transferred to secure facility. RP stated he had no concerns regarding Resident #1 care while at the facility. RP stated Resident #1 is doing well at the new facility.Record Review of Elopement Assessments dated 04/09/2025, revealed all current residents were assessed for elopement /wandering risk. No new residents were identified to be at high risk.On 07/02/2025 at 3:45 PM, the acting Administrator was informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 04/08/2025 and ended on 04/14/2025. The facility had corrected the noncompliance before the investigation began. The interventions and plan for correction included:Review of Resident #1 discharge paperwork revealed she was discharged on 04/14/25 to a secure facility.Review of Resident #1 EMR revealed Resident #1 was on 1:1 supervision with a caregiver until she was transferred to the new facility.Review of facility in-services dated 04/09/25 revealed all staff were educated regarding elopements, securing doors and activating alarms, abuse and neglect and supervision of residents. Staff were instructed to notify DON, Admin regarding any attempts of elopement or resident who may have increased confusion and attempt to exit. Staff were to ensure all exit gates are closed.Review of Elopement drills dated 04/09/25-04/11/25 revealed a drill was completed on all shifts. Review of Ad Hoc QAPI meeting held on 4/9/25 revealed an QAPI meeting was held to discuss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455715 If continuation sheet Page 3 of 4 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 07/02/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the elopement of Resident #1.Review of Elopement Assessments dated 4/9/25 revealed current residents were assessed for elopement/wandering risk. No newresidents were identified to be at high risk.Observations at facility on 7/1/25 did not reveal observations of exit seeking or wandering residents.Interviews with facility staff on 7/1/25-7/2/25 revealed they were educated on elopements, securing doors and alarms, supervision ofresidents, abuse and neglect, and reinforcement of monitoring procedures.Interview with the facility's new maintenance supervisor revealed he is checking the locks and alarms each day to ensure they are working properly. Event ID: Facility ID: 455715 If continuation sheet Page 4 of 4