Health inspection·September 11, 2025

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for 1 of 3 discharged residents (Resident #29) reviewed for closed records. The facility failed to complete and transmit a discharge MDS assessment for Resident #29, who discharged on [DATE], within 14 days of the discharge date . This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings included: Record review of Resident # 29's admission face sheet undated reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, hypertension (high blood pressure), hyperlipidemia (fat particles in the blood), major depressive disorder, adjustment disorder, dehydration, insomnia, shortness of breath, hypokalemia, anxiety disorder, edema, muscle wasting and atrophy, dysphagia, acute upper respiratory infection, edema, dyspnea, and cognitive communication deficit. Record review of Resident # 29's nursing progress note dated [DATE] reflected Resident # 29 expired on [DATE] at 7:52 AM. Record review of Resident # 29's MDS list in PCC on [DATE] reflected Resident # 29's last transmitted MDS was her Annual MDS dated [DATE]. Review of the warnings associated with Resident # 29's MDS transmission reflected Death-ARD complete by [DATE]-93 days overdue. Interview on [DATE] at 11:39 AM with LVN A, when asked who was responsible for completing the resident MDS assessment LVN A stated they were responsible for completing the resident MDS assessment. LVN A stated each resident should have a discharge MDS assessment completed upon discharge. LVN A stated it was important for residents to have discharge MDS assessments conducted because it was a record keeping tool for the state, and it was a cut off or end Date for CMS purposes. LVN A stated there was not a reason that the discharge MDS assessment was not completed for Resident # 29 other than it was just overlooked and missed, and it was a mistake. LVN A stated it was her expectation that MDS assessments were to be completed on time and accurately. Interview on [DATE] at 11:45 AM with the DON revealed LVN A was responsible for completing resident MDS assessments. The DON stated all residents discharged should have discharge MDS completed. The DON stated it was important to complete a discharge MDS, so the plan of care is documented of who the providers are, what services are provided to the resident, and any upcoming appointments. The DON stated for a death MDS it was important those were completed to be able to know where the resident discharged to and what they expired from and to let CMS know to stop any payments to the facility. The DON stated it was their expectation that MDS assessments were completed timely and accurately. Interview on [DATE] at 11:50 AM with the ADM revealed that LVN A was responsible for completing resident MDS assessments. The ADM stated all residents discharged should have a discharge MDS completed. The ADM stated it was important to have a discharge MDS completed so documentation can be shown that a safe discharge was provided to the family. The ADM stated in the event of death he was unsure if a MDS assessment was needed. The ADM stated he was also unsure if not having a death MDS completed could affect CMS funding. The ADM stated it was his expectation that MDS Residents Affected - Few Page 1 of 7 455715 455715 09/11/2025 Monument Rehabilitation and Nursing Center 120 State Loop 92 LA Grange, TX 78945

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments are completed timely and accurately to protect resident care and overall well-being.Attempted record review of facility MDS policy reflected policy requested from ADM on [DATE] at 5:15 PM. The ADM replied on [DATE] at 10:17 AM that the facility follows the RAI manual.Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated [DATE], revealed OBRA Discharge assessments -Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted 455715 Page 2 of 7 455715 09/11/2025 Monument Rehabilitation and Nursing Center 120 State Loop 92 LA Grange, TX 78945

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 establish and 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 2 of 4 residents reviewed for during medication passMA B failed to wash her hands prior or during medication administration to Resident #21and Resident #43.These failures could place residents at risk for developing wounds, upper respiratory infections and risk for healthcare associated cross-contamination and infections. Findings include: Review of Resident #21's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: coronary heart disease (term for the buildup of plaque in the heart's arteries that could lead to heart attack or ischemic stroke), hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.), Diabetes Mellitus Type 2, (A condition results from insufficient production of insulin, causing high blood sugar.) and dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Review of Resident #43's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body)., Hyperlipidemia (is an excess of lipids or fats in your blood) and dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Observation on 09/11/2025 at 10:14 am revealed MA B at her medication cart in the 200 hallway. MA B prepared Resident #43's medication and took them to Resident #43. MA B did not perform hand hygiene before or after medication administration to Resident #43. MA B then went down the hall. Observation on 09/11/2025 at 10:25 AM revealed MA B preparing Resident #21's medications. MA B administered Resident #21's medications. MA B did not perform hand hygiene before or after Resident #21's medication administration. In an interview on 09/09/2025 at 10:30 am MA B stated she did not perform hand hygiene before, during or after administering medications to Resident #21 or Resident #43 and should have. She stated she should wash her hands between each resident to prevent cross contamination. In an interview on 09/11/2025 at 11:13 AM the DON stated it was her expectations that MA B wash her hands during medication pass before and between residents. She stated she provided the staff member with Inservice training after being made aware of the situation. She stated failure to perform hand hygiene during medication administration could lead to cross contamination or infections. Review of the facility's policy Hand Hygiene dated 10/24/2022 reflected All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. Residents Affected - Few 455715 Page 3 of 7 455715 09/11/2025 Monument Rehabilitation and Nursing Center 120 State Loop 92 LA Grange, TX 78945

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 3 of 5 residents reviewed for immunizations. (Residents #14, #28 and #5) A) The facility failed to document in Resident #14's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. B) The facility failed to document in Resident #28's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects (VIS-Vaccine information sheet), for the influenza immunization and the pneumococcal immunization. C) The facility failed to document in Resident #5's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, for the influenza immunization and the pneumococcal immunization. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings include: A) Review of Resident #14's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), cognitive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.), and diabetes mullites type II (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #14's quarterly MDS dated [DATE] reflected Resident #14 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #14 was further assessed to receive the influenza vaccine on 09/29/2024. Resident #14 was assessed to not have the pneumococcal vaccination with stated reason offered and declined. Review of Resident #14's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #14's EMR on 09/11/2025 reflected under the immunizations tab in PCC that Resident #14 received the influenza vaccination on 09/29/2024, no other immunizations were recorded. Review of Resident #14's admission paperwork dated 12/18/2023 reflected no informed consent or vaccination information sheet (VIS) for the pneumonia vaccination. B) Review of Resident #28's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), peripheral vascular disease (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and aphasia(A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.). Review of Resident #28's quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #28 was assessed to have the influenza vaccine dated 09/29/2024. Resident #28 was assessed to not be up to date on the pneumococcal. Review of Resident #28's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #28's resident admission agreement dated 09/07/2023 reflected Resident #28 refused the influenza and pneumococcal. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP regarding influenza and pneumococcal vaccinations. C) Review of Resident #5's face sheet dated 09/11/2025 reflected an [AGE] year-old male admitted to the Residents Affected - Some 455715 Page 4 of 7 455715 09/11/2025 Monument Rehabilitation and Nursing Center 120 State Loop 92 LA Grange, TX 78945

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion.) and malignant neoplasm of pancreas (cancer). Review of Resident #5's Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #5 was assessed to not receive influenza, pneumococcal, offered and declined. Review of Resident #5's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #5's resident admission agreement dated 09/03/2024 reflected last known pneumococcal vaccination question was blank. Review of the consent reflected the RP wanted the resident to receive the pneumococcal and influenza vaccinations. Review of Resident #5's resident informed consent for influenza immunization dated 09/29/2024 reflected Resident #5 refused the influenza immunization. The consent was signed by the resident. In an interview on 09/11/2025 at 1:02 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. She stated the facility did not have a policy for immunizations that they used the CDC guidelines. In an interview on 09/11/2024 at 1:15 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the IP but since the current IP was not yet certified the DON who is certified was doing it and had not yet come up with a system to keep track of the immunizations. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the CDC guidelines on the www.cdc.gov website reflected Pneumococcal conjugate vaccine helps protect against bacteria that cause pneumococcal disease. There are several pneumococcal conjugate vaccines (PCVs). The specific PCV and number of doses recommended are based on a person's age, vaccination history, and medical status. Adults 50 years or older who have not previously received PCV should receive a PCV vaccine. Some adults in this group who have already received PCV might be recommended to receive another dose. CDC recommends everyone 6 months and older get vaccinated every flu season. Children 6 months through 8 years of age may need 2 doses during a single flu season. Everyone else needs only 1 dose each flu season. 455715 Page 5 of 7 455715 09/11/2025 Monument Rehabilitation and Nursing Center 120 State Loop 92 LA Grange, TX 78945

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 3 of 5 residents who were reviewed for immunizations. (Residents #14, #28 and #5) The facility failed to document in Resident #14, #28 and #5's medical records for having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: Review of Resident #14's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), cognitive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.), and diabetes mullites type II (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #14's quarterly MDS dated [DATE] reflected Resident #14 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #14's MDS did not address her current COVID-19 status. Review of Resident #14's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #14's EMR on 09/11/2025 reflected under the immunizations tab in PCC that Resident #14 received the influenza vaccination on 09/29/2024, no other immunizations were recorded. Review of Resident #14's admission paperwork dated 12/18/2023 reflected no informed consent or vaccination information sheet (VIS) for the COVID-19 vaccination. Review of Resident #28's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), PVD (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and aphasia(A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.). Review of Resident #28's quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #28 MDS did not address her current COVID-19 status. Review of Resident #28's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #28's resident admission agreement dated 09/07/2023 reflected no entry regarding the COVID-19 vaccination. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP the COVID-19 vaccination. Review of Resident #5's face sheet dated 09/11/2025 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion.) and malignant neoplasm of pancreas (cancer). Review of Resident #5's Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #5's MDS did not address her current COVID-19 status. Review of Resident #5's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #5's resident admission agreement dated 09/03/2024 reflected no entries related to COVID-19 vaccinations. Review of Resident #28's EMR on 455715 Page 6 of 7 455715 09/11/2025 Monument Rehabilitation and Nursing Center 120 State Loop 92 LA Grange, TX 78945

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 09/11/2025 reflected no VIS were given to the resident or RP the COVID-19 vaccination. In an interview on 09/11/2025 at 1:02 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. She stated the facility did not have a policy for immunizations that they used the CDC guidelines. In an interview on 09/11/2024 at 1:15 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the IP but since the current IP is not yet certified the DON who is certified is doing it and had not yet come up with a system to keep track of the immunizations. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the CDC guidelines on the www.cdc.gov website reflected CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older. Parents of children ages 6 months to 17 years should discuss the benefits of vaccination with a healthcare provider. 455715 Page 7 of 7