Grace Pointe Wellness Center: Narcotic Tracking Failures - TX
A complaint inspection completed December 31, 2025 found staff at the El Paso facility had failed to follow the facility's own controlled medication policy, which required nurses to enter the date, time, amount administered, and their signature on an accountability record completed after the medication was actually given. The gap between what the policy required and what nurses were doing left the narcotic count sheets incomplete and, according to one of the facility's own nurses, created the conditions for a resident to be dosed twice.
LVN B, interviewed by inspectors that afternoon, laid out how the system was supposed to work. Nurses pull the medication, confirm it's correct, document the resident's name, the medication, the dosage, and the time on both the electronic medication administration record and the paper narcotic count sheet. At shift change, two nurses count together and confirm no discrepancies. The Director of Nursing monitors the count sheets, LVN B said, though he wasn't sure how often she reviewed them.
He was certain about one thing. If a nurse pulled a narcotic and didn't document it right away, and another nurse later looked at the count sheet and saw no record of that dose, that second nurse might administer the medication again. "The risk for the resident," he said, "included double dosing the resident."
The DON, interviewed about forty minutes later, described the same process. Nurses document on the EMAR and the narcotic count sheet as they pull medications. The shift-change count is performed by two nurses. She monitors the sheets monthly, or when nursing staff flag a discrepancy. The purpose of accurate EMAR documentation, she said, was "to ensure the resident was being treated accurately, according to the physician's orders."
The medication assistant, identified in the report as MA A, said the facility had conducted an in-service on the five rights of medication administration. She could not recall when it was held.
The ADON and DON were identified as the staff responsible for monitoring the narcotic count sheets overall.
Inspectors classified the violation as causing minimal harm or potential for actual harm, with few residents affected. The classification sits at the lower end of the federal harm scale, but the mechanism the facility's own nurse described, an undocumented narcotic dose invisible to the next nurse who checks the count, is not a theoretical risk. It is a documentation failure with a direct path to a resident receiving a controlled medication twice in a single shift.
Narcotics prescribed in nursing home settings often include opioid pain medications. Double dosing carries real consequences for elderly residents, who metabolize medications more slowly and are more vulnerable to respiratory depression and sedation than younger patients.
The facility's written policy, dated 2025, was unambiguous. The accountability record is to be completed after the medication is actually administered, not at the end of a shift, not when a nurse finds a spare moment. The inspection found that standard wasn't being met.
What the records didn't show was how long the documentation gaps had been occurring, how many doses went unrecorded before the complaint triggered the inspection, or whether any resident had already received a double dose without anyone catching it. The count sheets that were supposed to answer those questions were the same count sheets that weren't being filled out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grace Pointe Wellness Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Grace Pointe Wellness Center in El Paso, TX was cited for violations during a health inspection on December 31, 2025.
LVN B, interviewed by inspectors that afternoon, laid out how the system was supposed to work.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.