Health inspection·December 1, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few maintenance giving his word would be done by time Football game is on. Person (s)/Departments Contacted: Maintenance 09/05/25 and ADON 09/09/25. Summary/Findings was left blank. Recommendations/Actions Taken: TV is not compatible to any remotes. Pt. had talked to Admin about getting a new TV and need to call cable service. Pt. says TV is not the issue. Identify the method (s) used to notify the resident and/or resident representative of the resolution: The resolution was left blank. The Grievance/Concern form was signed by the Maintenance Director on 09/10/25. Review of an undated Grievance/Complaint Report for Resident #2 written by LVN ADON C revealed, Documentation of Grievance/Complaint related to: Activities Department. Description: Resident would like to participate in activities. However, they only speak Spanish language. Person (s)/Departments Contacted: Activities Director 09/09/25. Summary/Findings was left blank. Recommendations/Actions Taken: Was left blank. Resolution of Grievance/Complaint: Was left blank. Identify the method (s) used to notify the resident and/or resident representative of the resolution: Was left blank. Date of notification: 09/09/25. The Activities Director signed the form on 09/10/25. During an interview and record review on 09/25/25 at 9:56 AM, with Activities Director revealed she wrote a Grievance Report for Resident #2, regarding the resident's concern that activities were done in Spanish. She said she had a communication barrier, because she could only speak little English and the resident did not speak Spanish. She said she had explained to the resident, there were three other residents at the facility who only spoke English, and they attended activities. She said the resident wanted to know why all activities were done in Spanish. She said the nurse on the fourth floor had assisted her in translating and explaining to Resident #2 that the monthly activities are scheduled according to the special holidays celebrated on a particular month and in September they celebrated the independence of Mexico. She said Resident #2 showed no interest to associate with other English-speaking residents because they were not Jewish. She said they offered activities, and she refused. The Activities Director stated she had documented a note on the back of the grievance form. The note reflected resident is a little confused by their requests, she assumes that the problem is that the activities are mostly done in Spanish, it was explained to her that this is because almost all the residents speak Spanish but the group can still be included and it will be explained in English to her and to three other residents who only speak English and who do participate in activities but she doesn't want to. She doesn't want to do in-room activities because she wants to be private in her room, but she also doesn't want to go to the dining room with other residents. She says she likes chess and was offered to socialize with the people who speak English. She said yes, but she didn't want to be bothered. And she started talking about financial matters to be here in the building. I think she can't adapt and wants things done that are difficult to understand, not because of the language, but because of her needs. During an interview on 09/25/25 at 10:42 AM, with Maintenance Assistant revealed the televisions were not programmed to only see Spanish channels. He said they provided cable services to all the residents, and they had access to sixty-five channels. He said that he was not aware of any residents having issues with the TV channels. He said he had not assisted in resolving any concerns related to televisions. During an interview on 09/25/25 at 10:44 AM the Maintenance Director revealed he had been employed at the facility for five months. He said they did not have compatible remotes for Resident #2's TV, and she was only able to use subscription entertainment. He said he did not know the name of the contracted cable company and was waiting for the Administrator to provide him with the information for the cable company to come and check Resident #2's cable connection. He said, the Administrator gave a universal remote to Resident #2 that was when I found out there was no cable service in that room. He said Resident #2's television worked but only accessed Spanish channels. He said the resident informed him, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 2 of 7 Printed: 05/15/2026 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 675106 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 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: 675106 If continuation sheet Page 3 of 7 Printed: 05/15/2026 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 675106 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: 675106 If continuation sheet Page 4 of 7 Printed: 05/15/2026 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 675106 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 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide to send a copy of notice to the Office of the State Long-Term Care Ombudsman at least 30 days prior to the discharge or as soon as possible for 1 (Resident #2) of two residents reviewed for facility-initiated discharges, in that: The facility failed to send a copy of the Discharge Notice at the same time notice was provided to Resident #2 on 09/03/25 to the Local Office of the State-Long Term Care Ombudsman. This failure could place residents at risk of not providing added protection to residents from being inappropriately transferred or discharged and provide residents with access to an advocate who can inform them of their options and rights. Findings included:Review of the admission Record dated 09/24/25, revealed Resident #2 was admitted on [DATE] from home. Review of History & Physical dated 08/08/25 revealed Resident #2 was a [AGE] year-old female GAD (Severe, ongoing anxiety that interferes with daily activities), bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and behavior), DM2 (a chronic metabolic disorder characterized by high blood sugar levels due to insulin deficiency), HTN (is a condition where the force of blood flowing through the arteries is consistently too high), CHF (a condition where the heart muscle weakens and cannot pump blood effectively), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks its own healthy tissues and organs). Alert and oriented x 1-2. Review of admission Minimum Date Set (MDS) dated [DATE] for Resident #2 revealed the resident admitted from home, BIMS Summary Score 15 (cognitively intact). Active Diagnoses - Diabetes Mellitus, Anxiety Disorder, Lupus, Heart Failure, Hypertension; Medications - insulin injections, antipsychotic, antianxiety, opioid, anticonvulsant; oxygen. The resident participated in the assessment. The resident's overall goal during the assessment process - remain in the facility. Is active discharge planning already occurring for the resident to return to the community? No. Review of Care Plan initiated 08/29/25 revealed: Resident had a history of making false accusations. Interventions: Social Services/Administrator to interview the resident after each accusation. Date Initiated: 09/22/2025.The resident has potential to demonstrate verbally abusive behaviors Ineffective coping skills, Mental /Emotional illness Date Initiated: 09/22/2025 Interventions: Notify the charge nurse of any abusive behaviors. Psychiatric/Psychogeriatric consult as indicated.Resident to remain in facility long term as he/she requires 24-hour licensed nursing care Date Initiated: 09/22/2025. Review of a Notification of discharge date d 09/03/25 for Resident #2 revealed, This letter is written notification that the above resident, [Resident #2], will be discharged from the nursing facility effective thirty-one days from the receipt of this letter. This discharge is based on your failure, after reasonable and appropriate notice, to pay for services provided and your stay at the facility. The facility staff will work with you to make preparations needed to ensure a safe and orderly transition. An orientation for discharge planning will be held on 09/09/25. [Resident #2] will be discharged to the following address. The choosing of resident with assistance from discharge team. You have the right to appeal this decision as outlined in the Health and Human Services Commission's Fair Hearings, Fraud and Civil Rights Handbook. You may also contact the regional representative of the Office of the State Long Term Care Ombudsman, HHSC. A copy of this letter has been sent to the local Ombudsman. You may also contact the Texas Long Term Care Ombudsman toll-free at (800) [PHONE NUMBER]. Resident #2 and the facility's Administrator signed the document on 09/03/25. During a telephone interview on 09/24/25 at 10:38 PM, the Local Ombudsman revealed he had visited Resident #2 09/23/25 and she had not mentioned anything about being given discharge notice. He said she had called him two weeks ago to discuss room rates. He said that as far as he knew the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675106 If continuation sheet Page 5 of 7 Printed: 05/15/2026 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 675106 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: 675106 If continuation sheet Page 6 of 7 Printed: 05/15/2026 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 675106 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: 675106 If continuation sheet Page 7 of 7