Health inspection·December 31, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services.The facility failed to document accurately on Resident #1's EMAR for Acetaminophen with Codeine 300-30 MG tablet, 1 tablet. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.Findings included:Record review of Resident #1's face sheet dated 12/29/25 noted she was a [AGE] year-old female with admission date 08/28/25.Record review of Resident #1's health and physical dated 12/23/25 revealed a medical history of Lupus Erythematosus (an autoimmune disease where the immune system mistakenly attacks the body's own tissues, causing inflammation and tissue damage).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact.Record review of Resident #1's care plan, last revised 12/29/25, revealed resident had a potential for uncontrolled pain secondary to Systemic Lupus Erythematosus. Staff intervention included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Nursing staff were to evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability.Record review of Resident #1's physician order dated 10/22/25 noted medication Acetaminophen with Codeine 300-30 MG tablet Give 1 tablet by mouth every 6 hours as needed for pain.Record review of Resident #1's physician order dated 11/05/25 noted medication Acetaminophen with Codeine 300-30 MG tablet Give 2 tablets by mouth every 6 hours as needed for pain.Record review of Resident #1's Electronic Medication Administration Record (EMAR) revealed resident was administered Acetaminophen-Codeine Oral tablet 300-30 MG Take 2 tablets by mouth as needed for pain as notated by nursing staff on the following dates: 11/08/25 at 08:01 AM, 02:02 PM, 08:00 PM; 11/15/25 at 07:01 AM, and 12:59 PM.Record review of Resident #1's Narcotic Count Sheet revealed nursing staff pulled 1 tablet of Acetaminophen-Codeine Oral tablet 300-30 MG on the following dates: 11/08/25 at 08:00 AM, 02:00 PM, and 08:00 PM; 11/15/25 07:00 AM, and 1:00 PM.Interview on 12/29/25 at 10:50 AM with Resident #1, she stated she was provided 1-2 tablets during the month of November and was only aware of her medication order Acetaminophen-Codeine Oral tablet 300-30 MG take 2 tablets by mouth and was unsure why she would only receive 1 tablet at times.Interview on 12/31/25 at 1:32 PM with MA A revealed only nurses were to administer narcotic medication as needed to residents. She stated nursing staff were trained to perform the 3 checks, confirming the medication label matches the physician order when pulling medications. They stated 3 checks including confirming the name of resident, medication, dosage, time, and how many tablets, before, when, and after pulling medication. She stated nursing staff were trained to document on the EMAR and Narcotic Count Sheet when pulling the medication. MA A stated the nurse pulling the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675106 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 12/31/2025 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)