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Complaint Investigation

Grace Pointe Wellness Center

December 1, 2025 · El Paso, TX · 2301 N Oregon St
Citations 4
CMS Rating 1/5
Beds 154
Provider ID 675106
Healthcare Facility
Grace Pointe Wellness Center
El Paso, TX  ·  View full profile →
Inspection Summary

GRACE POINTE WELLNESS CENTER in EL PASO, TX — inspection on December 1, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0585
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During an interview on 09/25/25 at 12:20 PM, with the Administrator revealed he was aware Resident #2 did not have TV cable services and that her TV was only showing Spanish channels. He said he had placed an order for new televisions and was pending corporate approval.

The state surveyor requested a copy of the invoice to purchase new televisions.

During an interview on 09/25/25 at 1:00 PM with the DON revealed, the Administrator was managing the Grievances until they hired a new social worker.

During an interview on 09/25/25 at 4:00 PM with the Administrator, he said he did not have an invoice for purchasing multiple televisions. He said the process they used to buy things such as televisions was to notify the Area director of Operations and they would forward the request to the corporate office.

Review of the facility's policies and procedures on Grievances revised 11/02/2016, revealed the resident had the right to voice grievance to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal.

Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay.

The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievance the resident may have.

Procedure: The grievance official of this facility is the administrator or their designee.

The grievance official will: Oversee the grievance process; Receive and track grievances to their conclusion; Lead any necessary investigations by the facility; Issue written grievance decisions to the resident; Coordinate with state and federal agencies, as necessary.

All written grievances decisions will include: The date the grievance was received. A summary statement of the resident's grievance.

The steps taken to investigate the grievance. A summary of the pertinent findings or conclusions regarding the residents' concerns. A statement as to whether the grievance was confirmed or not confirmed.

Any corrective action taken or to be taken by the facility as a result of the grievance.

The date the written decision was issued.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Pointe Wellness Center

2301 N Oregon St El Paso, TX 79902

SUMMARY STATEMENT OF DEFICIENCIES

During an interview and record review 09/25/25 at 5:15 PM with the HR Coordinator revealed the annual last EMR and NAR screening on LVN A was completed on 08/12/24.

She said, This one was over-looked and was not completed until 9/10/2025. We will be changing the process of completing the annual EMR and NAR on each employee's anniversary date to ensure the annual EMR and NAR screenings are completed annually according to company policy and state requirements.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Pointe Wellness Center

2301 N Oregon St El Paso, TX 79902

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/24/25 at 11:42 AM with the Administrator, he said he had issued Resident #2 a Discharge Notice on 09/03/25, because she had not qualified financially for Medicaid and did not have sufficient resources to pay the rate for a private room. He said that he had informed the resident that if she chose to have a private room, she had to pay the monthly rate for a private room or she would be given a discharge notice, according to facility's policy on discharges for non-payment.

During an interview on 09/24/25 at 1:59 PM, the Administrator revealed he had explained to Resident #2 why she had not qualified financially for Medicaid. He said the resident paid for a semi-private room and did not want to have a roommate because she had PTSD. He said he had explained to the resident, she would have to pay the monthly rate for a private room, since she did not want to have a roommate. He said the resident could not afford to pay the monthly rate for a private room. He said he had given her a discharge notice on 09/03.25. He said he had emailed a copy of the Discharge Notice to the Ombudsman.

The state surveyor requested a copy of the email sent to the Ombudsman notifying him of the Resident #2's discharge notice.

During an interview on 09/25/25 at 6:06 PM with the Administrator revealed, he had not sent the local Ombudsman a copy of Resident #2's Notification of Discharge Notice given to the Resident #2 on 09/03/25.Review of facility's Policy on Discharge or Transfer revised 02/12/2025 revealed, Facility Initiated Discharge - The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiative transfer or discharges: The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicate or Medicaid, for his or her stay at the facility.

Notification of Discharges: For a facility-initiated non-emergent transfer or discharge of a resident, the facility will notify the resident and resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand with at least 30 days' notice prior to discharge.

Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Pointe Wellness Center

2301 N Oregon St El Paso, TX 79902

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 154 beds, failed to employ a qualified social worker on a full-time basis since 08/14/2025.

This failure put facility residents at risk of not having their psychosocial or discharge planning needs met.

Findings included:

Record review of the facility census dated 09/24/2025 revealed that the facility had a capacity of 154 beds and had a census of fifty-four.

During an interview and record review on 09/25/25 at 12:49 PM with the Administrator revealed, the Social Worker had resigned a month ago. He said they hired a social worker on 08/29/25, and she only worked for about a week and resigned for personal reasons. He said they just hired a social worker to start on 10/07/25. He said their company had multiple facilities in town and he had not reached out for help with social services at his facility. He said the potential risk of not having a social worker could result in resident's psychosocial needs, grievances and coordination of resident discharges not being addressed.

Record review of the facility's undated policy Social Services revealed, the following is a non-exhaustive criterion that related to the job of a Social Worker, and it is consistent with the business needs of the facility.

Knowledge Base: A bachelor's degree in social work or secondary education in social services and certification as a social worker may be substituted as appropriate.

Social Worker Responsibilities: Purpose: To outline the role of the social worker in discharge planning to ensure safe transitions of care, regulatory compliance, and adequate coordination with residents, families, and the interdisciplinary team.

Scope: This procedure applies to social workers managing the psychosocial and coordination aspects of resident discharges.

Other duties as assigned.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL PASO, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRACE POINTE WELLNESS CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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