Grace Pointe Wellness Center
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
medication was responsible for documenting and administering medication per physician order. She stated
the potential risks of not documenting on the correct EMAR order for residents included harming the resident's health by over or underdosing. She stated the ADON and DON were responsible for monitoring Narcotic Count Sheets. MA A stated the facility did provide an in-service regarding the 5 rights for medication but was unable to recall the date.Interview on 12/31/25 at 2:34 PM with LVN B revealed only nurses were to administer narcotic medications. He stated nurses were to document on the EMAR and Narcotic Count Sheet immediately after pulling medication and confirming it was the correct medication. He stated it included name of resident, medication, dosage, and time. He stated nurses monitor Narcotic Count
during shift change, 2 nurses count and confirm there were no discrepancies. LVN B stated the DON monitored the Narcotic Count Sheets but was unsure how often. LVN B stated the risk for the resident included double dosing the resident.Interview on 12/31/25 at 3:14 PM with the DON revealed nursing staff were responsible for documenting on the EMAR and Narcotic Count sheet as they pull medications. She stated the purpose of accurately documenting the correct EMAR was to ensure the resident was being treated accurately, according to the physician's orders. She stated the narcotic count would trigger during shift change, which was completed by 2 nurses. She stated as the DON, she monitored monthly, or if notified by nursing staff of discrepancies.Record review of the facility's policy Controlled Medications-Administration dated 2025, read in part: when a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, completed after the medication is actually administered.
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GRACE POINTE WELLNESS CENTER in EL PASO, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.