Grace Pointe Wellness Center

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

she did not like to see Spanish channels, because she only speaks English. He said he had not documented a resolution on the Grievance form that he had signed on 09/10/25 because the Administrator was going to order new televisions and did not know if that had been done. He said he had not forgotten her, and the issue was the TV remotes were not working, and she could only get Spanish channels in the TV. He said the Administrator had said he was going to call the cable company to install cable in that room.

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Pointe Wellness Center

2301 N Oregon St El Paso, TX 79902

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)

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 10 employees (LVN A) reviewed for annual employee misconduct registry and nurse aide registry screenings, in that: The facility had failed to complete the annual employee misconduct registry and annual nurse aide registry screenings for LVN A. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included:Record review of facility's policy undated on Abuse/Neglect revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Procedure A. Screening: Criminal History and Background Checks All potential employees will be screened for history of abuse, neglect or mistreating of elderly/individuals as defined the applicable requirement of 483.13 (c) (1) (ii) (A) and (B). Employees will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry by calling the Texas Department of Aging and Disability at [PHONE NUMBER]. The hiring authority will follow the automated response prompts to screen the employee for abuse, neglect, exploitation of a resident or misappropriation of a resident's or consumer's property. The hiring authority is responsible for training an individual to complete misconduct registry checks on every employee. The facility is required to provide a written statement to the employee upon hire about the Employee Misconduct Registry including a statement indicating that a person may not be employed if listed on the registry. 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Pointe Wellness Center

2301 N Oregon St El Paso, TX 79902

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)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident had not been given 30-day notice. He said the resident did not want to be discharged . 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grace Pointe Wellness Center

2301 N Oregon St El Paso, TX 79902

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)

F 0850

Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet