Grace Pointe Wellness Center
GRACE POINTE WELLNESS CENTER in EL PASO, TX — inspection on December 31, 2025.
Found 1 citation. 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.
Inspection Findings
the ADON and DON were responsible for monitoring Narcotic Count Sheets. MA A stated the facility
medications. He stated nurses were to document on the EMAR and Narcotic Count Sheet immediately
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.