Cycle 1
Health 2025-09-11 · Fire 2025-09-11
6 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
La Grange, TX
Monument Rehabilitation and Nursing Center
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
120 State Loop 92, La Grange, TX
(979) 968-3144
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
57
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
1987-09-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.56
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.85
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.48
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,991
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.50% · Performance 22.39% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.13% · Performance 8.04% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.04
Baseline 73.21% · Performance 56.10% · Measure score 3.04 · Achievement 1.85 · Improvement 3.04
Adjusted total nurse staffing
0.64
Baseline 3.21 hours · Performance 3.26 hours · Measure score 0.64 · Achievement 0.64 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 17.31% · Lower 95% interval 7.81% |
| Discharge to community | 37.46% |
50.57%
13.1 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 28.26% · Lower 95% interval 26.08% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 84.09% |
95.27%
11.2 pts worse
|
Numerator 37 · Denominator 44 |
| Falls with major injury | 6.82% |
0.77%
6.1 pts worse
|
Numerator 3 · Denominator 44 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 20 · Denominator 30 |
| Discharge mobility score | 70% |
50.94%
19.1 pts better
|
Numerator 21 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 1 · Denominator 44 · Adjusted rate 2.18% |
| Healthcare-associated infections requiring hospitalization | 8.04% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 3.87% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 98.57% |
42%
56.6 pts better
|
Numerator 69 · Denominator 70 |
| Discharge function score | 76.67% |
56.45%
20.2 pts better
|
Numerator 23 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
97.1%
1 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 94.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.3%
2 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.9% · Q3 3.8% · Q4 4.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.6% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
18.9%
4.4 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 16.7% · Q3 14.6% · Q4 17.9% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
10.8%
7.7 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 7.9% · Q4 2.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.2% |
15.4%
10.2 pts better
|
16.3%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
16.1%
6.8 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 19.0% · Q3 19.5% · Q4 38.5% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.5% |
15.0%
1.5 pts worse
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 16.9% · Q3 15.0% · Q4 7.3% · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.3% · Q3 2.2% · Q4 2.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
89.7%
5.7 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 84.2% · 4Q avg 95.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
12.0%
0.3 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 12.9% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
88.0%
2 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.8% |
25.9%
7.9 pts worse
|
23.9%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.8% · Observed 38.7% · Expected 27.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-31 · Fire 2024-07-31
11 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-06
F · Potential for more than minimal harm
2025-09-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-06
E · Potential for more than minimal harm
2025-09-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-12-06
D · Potential for more than minimal harm
2024-07-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-28
E · Potential for more than minimal harm
2023-06-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-10
D · Potential for more than minimal harm
2023-06-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Not marked corrected
E · Potential for more than minimal harm
2025-09-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-09-11
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-11
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-17
J · Immediate jeopardy
2025-07-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-11
E · Potential for more than minimal harm
2024-07-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-31
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-31
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-31
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-08-08
B · Minimal harm
2024-07-31
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-08-08
D · Potential for more than minimal harm
2023-06-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-08
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-12
E · Potential for more than minimal harm
2023-03-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-14
Penalties and ownership
What sits behind the stars
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
120 State Loop 92 LLC
Operational/Managerial Control · Organization
Chudleigh, James
Operational/Managerial Control · Individual
Csv Rhea Management Holdco, LLC
Operational/Managerial Control · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Dwd Tx Holdings LLC
Operational/Managerial Control · Organization
Jack And Nancy Dwyer Workforce Development Center Inc
Operational/Managerial Control · Organization
Lucas, Denise
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Reg Bridge Opco LLC
Operational/Managerial Control · Organization
Reg Hg Opco LLC
Operational/Managerial Control · Organization
Reg Operator Holdco LLC
Operational/Managerial Control · Organization
Regency Ihs Clinical Consulting, LLC
Operational/Managerial Control · Organization
Regency Ihs Of La Grange LLC
Operational/Managerial Control · Organization
Regency Ihs Rehab LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Regency Texas Holdings LLC
Operational/Managerial Control · Organization
Rollo, Jeffery
Corporate Officer · Individual
Siptak, Trina
Operational/Managerial Control · Individual
Stramecki, Anthony
Corporate Officer · Individual
Vasquez, Raymundo
Operational/Managerial Control · Individual
Vratis, Kacey
Corporate Officer · Individual
Way, George
Corporate Officer · Individual
Winnie-Stowell Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Care Inn Of La Grange
La Grange, TX
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Schulenburg Regency Nursing Center
Schulenburg, TX
4-star overall rating with 4-star inspections with $8,827 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Parkview Manor Nursing And Rehabilitation
Weimar, TX
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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