Health inspection·January 28, 2026

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents remained free of any significant errors for 1 of 3 residents (Resident # 1) reviewed for medication error. The facility failed to ensure Resident #1 received the correct dosage of Primidone required for treating tremors. Resident #1 was given Primidone 50 mg oral tablet 1 tablet by mouth 2 times a day from 12/11/2025 until 01/07/2026. The order from the hospital discharge was written as Primidone 50 mg oral tablet 2 tablet by mouth 2 times a day. The failure could place residents at risk of complications such as increased tremors. The findings included: Review of Resident #1 face sheet, dated 01/28/2026, revealed he was initially admitted to the facility 12/11/2025 with diagnosis including, type 2 diabetes (body does not produce enough insulin), kidney disease (kidneys are not filtering correctly), urinary tract infection (bladder infection) and Essential tremor (shaking you can't control) Review of Resident #1's quarterly MDS assessment, dated 12/02/2025 revealed his BIMS score was 08 out of 15 reflective of moderate cognitive impairment Review of Resident #1's Care Plan, dated 12/11/2025, and revised 01/07/2026 revealed: Resident 1 had a medication error related to Primidone. Review of hospital report dated 12/11/2025 revealed order of Primidone (primidone 50 mg oral tablet) 2-tab Oral (given by mouth) 2 times a day. This medicine is given for his tremors Record review of Resident #1's orders on the EMR revealed:Primidone Oral Tablet 50 MG Give 1 tablet by mouth 2 times a day. Start date 12/11/2025 End date 01/07/2026.Primidone Oral Tablet 50 MG Give 2 tablet by mouth 2 times a day. Start date 01/07/2026. Record review on the MAR for the month of December and January revealed that Resident #1 was administered Primidone, 50mg, 1 tablet by mouth 2 times a day starting on 12/11/2025 through 01/07/2026. Record review on the MAR for the month of January 2026 revealed that Resident #1 was administered Primidone, 50 mg, 2 tablets by mouth 2 times a day starting 01/07/2026. Observation and interview on 01/28/2026 at 11:00am revealed Resident #1 lying in his bed watching tv. Resident # 1 engaged in conversation but was watching a tv show and did not want to talk much. He told me he has no concerns with his care. He wishes the food tasted more like home cooking. I did not observe any tremors during our conversation. Observation of medication pass on 01/28/2026 at 11:30 am revealed no concern with administering correct medications. Interview on 01/28/2026 at 10:00am with resident's family member revealed that the facility had called her because of Resident #1's increased tremors. The family member asked about how much Primidone was being administered and that was when the discrepancy was found. Interview with Admin on 01/28/2026 at 11:00am revealed that once they became that the order being written incorrectly in the MAR the facility had an interim director of nurses, who immediately spoke with the doctor, and corrected the order in Resident #1s MAR. Interview with DON 01/28/2026 at 11:00am who stated that the medication Primidone was used to treat Resident #1 tremors. Surveyor asked her what could happen if he did not receive the correct dose and she revealed the tremors could increase. DON told me the facility has a new system in place for when a resident was admitted and 2 nurses enter the medication and check it off. The DON then comes after and checks if it is in the system Residents Affected - Some (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 2 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 01/28/2026 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)