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Ambrosio Guillen Texas State Veterans Home

9650 Kenworthy St., El Paso, TX 79924 · El Paso County · (915) 751-0967

160 certified beds, about 152 residents a day · For profit - Corporation · Medicare and Medicaid since 2005

Veterans home Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 676060 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on April 9, 2026, inspectors cited 8 health deficiencies (the Texas average is 9.4, the national average 9.2).

None of its 43 health citations since December 2023 was rated as actual harm or immediate jeopardy.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.71 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.46 of those hours.

39.7% of nursing staff left within the year CMS measured (Texas average 55.3%).

CMS links it to Texvet, an affiliated group of 9 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 43 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
25D
18E
0F
Potential for minimal harm
0A
0B
0C
April 9, 2026Standard inspection · 8 citations
  1. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 14 residents (Resident #63, Resident #65, and Resident #148) reviewed for ADL care.- The facility failed on 04/2026 to ensure Resident #63's, Resident #65's and Resident #148's fingernails were clean and trimmed. This failure could place residents who required assistance with ADLs at risk for unmet care needs.
  2. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed on 04/07/2026 to ensure leftover food was properly covered and sealed in the walk-in refrigerator.-The facility failed on 04/07/2026 to ensure dietary staff maintained proper hygiene, as evidenced by a torn hairnet that allowed hair exposure during meal handling.-The facility failed on 04/07/2026 to ensure dietary staff practiced hand hygiene and glove changes per the facility policy after their hands became contaminated. These failures had the potential to place all residents who received meals from the kitchen at risk for foodborne illness due to improper food storage and handling practices.
  3. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to treat the resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents (Resident #127) reviewed for dignity. -The facility failed on 04/07/2026 to ensure Resident #127's Foley catheter bag had a privacy bag. The deficient practice could affect residents by contributing to poor self-esteem, dignity issues, and diminished quality of life.
  4. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents reviewed for accommodation of needs. The facility failed to ensure resident call lights were within reach for Resident # 15 on 04/07/2026. This failure placed residents at risk of having their needs unmet when they were unable to contact staff.
  5. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 2 of 6 residents (Resident #14 and Resident #24) reviewed for dementia care.-The facility failed to have a comprehensive person-centered care plan for Resident #14 by not including a diagnosis and focus area for dementia and dialysis diagnosis.-The facility failed to have a comprehensive person-centered care plan for Resident #24 that was completed within the previous 3 months. These failures could affect residents and put them at risk of not receiving care and services to meet their needs.
  6. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to review and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #24) reviewed for care plan accuracy. -The facility failed to have a comprehensive person-centered care plan for Resident #24 that was completed within the previous 3 months. These failures could affect residents and put them at risk of not receiving care and services to meet their needs.
  7. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observation, 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; and failed to have an established system in place for accurate reconciliation for 1 (East wing) of 2 medication carts that had residents with orders for controlled substances. The facility failed to ensure LVN C signed the form after counting and verifying that all controlled substances in the medication cart had been accounted for with the Controlled Medication Accountability Record on 04/09/26. The facility failed to ensure Resident #157's Lidocaine Patch was removed per Physician's Order. [...]
  8. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observation, interviews, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (300-hall) viewed for pharmacy services. The facility failed to ensure the 300-hall medication cart was clean and free from dried drippings, pieces of paper and a loose tablet. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.
March 19, 2026Complaint inspection · 2 citations
  1. E
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 1, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 9 residents (Resident #1 Resident #2, Resident #3, and Resident #4) reviewed for dignity.-The facility failed on 3/18/2026 to provide glucose reading for Resident #1, Resident #2, Resident #3, and Resident #4 in a private setting.-The facility failed on 3/18/2026 to provide insulin injection for Resident #1, Resident #2, Resident #3, and Resident #4 in a private setting. The deficient practice could affect residents by contributing to poor self-esteem, dignity issues, diminished quality of life, and leaking of protected health information.
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 1, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention program designed to provide safe, sanitary, and prevent the development and transmission of communicable diseases and infections for 5 of 12 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for transmission-based precautions.-LVN G failed to perform hand hygiene and change gloves after disposing the dirty wound dressings, disposing his PPE gown, and before cleaning the wound, and applying the new wound dressing on 03/14/2026.-LVN G failed to secure his PPE gown before wound care and disposed of it without putting on a new one while providing wound care on 03/14/2026.-RN A failed on 3/18/2026 to practice proper hand hygiene during glucose measuring and insulin injection. [...]
February 3, 2026Complaint inspection · 3 citations
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 13, 2026
    Inspectors wroteBased on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a residents physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 3 residents reviewed for change in condition. The facility failed to immediately inform the NP/MD on 12/10/25 of Resident #1's new diagnosis of osteomyelitis (bone infection). This failure could place residents at risk of serious decrease in health related to delayed treatment.
  2. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 13, 2026
    Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of MDS assessment, in that: Resident #1's Discharge MDS dated [DATE] did not accurately reflect the residents' diagnosis of Osteomyelitis (infection of the bone). This failure could place residents at risk of not receiving necessary care .
  3. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 13, 2026
    Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 of 1 (Resident #1) resident reviewed for accuracy and completeness of medical records.-The facility failed to document notification to NP/MD of osteomyelitis for Resident #1 on 12/10/25. These failures could place residents at risk of not receiving needed services.
November 20, 2025Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 23, 2025
    Inspectors wroteBased on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, includinginjuries of unknown source, were reported immediately to the State Survey Agency, for 1 of 4 residents (Resident #1) reviewed for abuse/neglect. The nursing facility failed to report Resident #1's allegation of abuse, alleging LVN B squeezed her left-hand, on 10/01/25 to the state survey agency within 2 hours of learning of the allegation. This failure could place residents at risk for abuse and neglect and result in increased risk of abuse andneglect not being reported within 24 hours to the State Agency to ensure appropriate investigation and corrective actions were taken.
September 15, 2025Complaint inspection · 4 citations
  1. E
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 24, 2025
    Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 10 employees (CNA A and CNA B) reviewed for annual employee misconduct registry and nurse aide registry screenings, in that: The facility had failed to complete annual employee misconduct registry and annual nurse aide registry screenings for CNA A and CNA B. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.
  2. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 24, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 2 (Resident #2 and Resident #12) of 5 residents reviewed for quality of care.1. The facility failed to ensure the call light was within reach, assist bars were in place, and the bedside table was positioned away from Resident #2 on 8/28/25.2. The facility failed to ensure an PT/OT evaluation was completed for Resident #12, who required an assessment for assist bars to support bed mobility. These failures could place residents at risk for falls, injuries, loss of independence, and unmet care needs, which may result in a decline in overall health, safety, and quality of life.
  3. D
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 24, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff possess the competencies and skill sets necessary to provide nursing services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 1 staff member (RN C) reviewed for nursing services. 1. The facility failed to ensure RN C followed the facility's policy on blood sugar checks for Resident #6 by delegating the task to Certified Nurse Aide.2. The facility failed to ensure RN C administered injections according to the facility's policy and procedures to Resident #7. These failures could place residents at risk of being cared for not receiving nursing services by adequately trained and licensed staff, which could result in injury and infection.
  4. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 24, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #6) of 2 residents reviewed for pharmaceutical services.-The facility failed to administer insulin to Resident #6 according to physician orders.-The facility failed to ensure LVN D administered insulin to Resident #6 according to Manufacturer's Specifications. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.
April 3, 2025Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2025
    Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures for 1 of 3 residents (Residents #10) reviewed for misappropriation of property. [...]
January 31, 2025Standard inspection · 7 citations
  1. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 7 of 15 residents reviewed for residents' rights, in that: -In the memory care unit, facility failed to serve 7 of 15 residents their meals at the same time as their tablemates, causing them to watch their tablemates eat while they waited up to 30 minutes for their meal. This failure could affect residents' self-esteem and dignity.
  2. E
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure residents were made aware of the grievance process for 5 of 12 Residents who were reviewed for their knowledge of the facility's grievance procedures and grievance resolutions during resident council meeting. The facility did not ensure residents or staff were aware of the facility's formalized grievance process. This deficient practice could place the residents at risk for decreased quality of life and feelings of hopelessness.
  3. E
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #68 and Resident #142) of 2 residents observed for oxygen management. -Resident #68 utilized oxygen in his room and did not have an oxygen sign posted outside of the room. -Resident #142 utilized oxygen in her room and did not have an oxygen sign posted outside of the room. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms.
  4. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2025
    Inspectors wroteBased on observation, 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 (Resident #26) of 4 reviewed for medication administration; 4 (Halls 400-800) of 7medication carts reviewed for controlled substances; 1 of 2 medication room reviewed for storage of medications. 1. -The facility failed to ensure Licensed Staff H signed the Controlled Drugs-Audit Record form after counting and verifying that all controlled substances in the medication cart had been accounted for with the off- going nurse at the change of shift. 2.- -The facility failed to ensure Licensed Staff G signed the individual control drug record for resident #26 after administering controlled medication. 3. [...]
  5. E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 4 of 7 nurse carts checked for medication storage; 1 of 1 treatment carts checked for storage of supplies. -The facility failed to ensure liquid medication stored in medication carts on three halls (300, 700 and 800) did not have dried drippings on the sides of the bottles. - The facility failed to ensure bottle of Betadine stored in the treatment cart was free of dried drippings. These failures could affect residents that received medications at the facility by placing them at of risk cross contamination.
  6. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide foods which were palatable, attractive, and at an appetizing temperature for 1 of 1 meal observed for food preparation. (lunch 01/28/25) The facility did not serve food at an appetizing temperature for the lunch pureed, regular, and mechanical soft meals. The pureed diet fried zucchini and Albondiga (meatball) soup were below acceptable hot food temperature of 135 F or higher. The regular diet fried zucchini was below acceptable hot food temperature of 135 F or higher. The mechanical soft diet fried zucchini and Albondiga (meatball) soup were below acceptable hot food temperature of 135 F or higher. This failure could place residents who consumed food prepared in the kitchen at risk for reduced meal satisfaction and diminished nutritional intake.
  7. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 1 of 13 residents (Resident #24). Resident call lights were not kept within reach for 1 resident (Resident #24). This failure placed residents at risk of having needs unmet when they are unable to contact staff.
November 18, 2024Complaint inspection · 1 citation
  1. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 2 (Resident #3 and Resident #12) of 14 residents reviewed for administration. -The facility failed to document in Resident #3's MAR/TAR medical records, a behavioral incident that was being tracked on the MAR/TAR. - The facility failed to document in Resident #12's MAR/TAR medical records, a behavioral incident that was being tracked on the MAR/TAR. These failures could place residents at risk of not receiving needed services or errors in treatment based on incorrect information.
July 26, 2024Complaint inspection · 3 citations
  1. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 30, 2024
    Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one resident (Resident #3) of three residents reviewed for catheter care. -Resident #3's catheter drainage collection bag was lying on the floor. This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (an infection in any part of the urinary system).
  2. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 30, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #3) of 4 residents observed for oxygen management. Resident #3 was on oxygen and did not have oxygen signs posted outside his bedroom. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health; and place them at risk of an unsafe environment which could lead to accidents and injuries.
  3. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 30, 2024
    Inspectors wroteBased on, interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #3) of 8 residents reviewed for medical records. -The facility failed to ensure a physician's order for PRN oxygen for Resident #3 was documented. This failure could lead to errors in treatment based on incorrect information.
May 31, 2024Complaint inspection · 2 citations
  1. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 21, 2024
    Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 16 residents (Resident #8 and Resident #16) reviewed for accuracy of assessments. The facility failed to ensure Resident #8's MDS accurately reflected his g-tube status. The facility failed to ensure Resident #16's MDS accurately reflected his behaviors. These failures could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life.
  2. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 21, 2024
    Inspectors wroteBased on interviews and record review the facility failed to implement care interventions in accordance with each resident's written plan of care for 1 of 16 residents (Resident #8) whose care was reviewed. The facility failed to implement behavior focused area and interventions for Resident #8's pulling on drainage. This failure could affect residents monitoring that could result in injury.
April 24, 2024Complaint inspection · 1 citation
  1. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 7 (Resident #1) residents reviewed for abuse. The facility failed to immediately suspend CNA B after CNA A reported suspected roughness when CNA B was providing care to Resident #1. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
December 1, 2023Standard inspection, Complaint inspection · 10 citations
  1. E
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #72, #200, and #54) of 26 residents reviewed for reasonable accommodation of resident needs. The facility failed to ensure that Residents #72, #200 and #54's call lights were where they could be reached by the resident. This failure put residents at increased risk of not having their needs met on a timely basis and at increased risk of falls.
  2. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Resident #18, Resident #106, and Resident #118) reviewed for care plans. - The facility failed to implement an accurate code status in Resident #18 ' s care plan. -The facility failed to implement COVID diagnosis protocols in Resident #106 ' s care plan. -The facility failed to develop and implement a comprehensive person-centered care plan for Resident #118 ' s behaviors of going into other residents' rooms and take their personal belongings. [...]
  3. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 4 medications carts (Hall 300, 400 and 600) reviewed for medication storage and 1 (#59) of 6 resident reviewed for medication administration . -The facility failed to keep medication drawer free of dust and paper particles in the 400 Hall. -The facility failed to store medications separately according to routes of administration in the 400 and 600 halls. -The facility failed to ensure liquid medication stored in medication cart did not have dried drippings on the sides of the bottles in the 300 Hall. -The facility failed to accurately document the prescribed dose in physician orders and medication administration for resident #59.
  4. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 8 of 8 residents reviewed with diet orders for pureed texture. -Cook #2 did not follow established facility recipes when preparing pureed foods. These failures placed residents who received pureed diets at risk of inadequate nutrition and weight loss.
  5. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to store foods in walk-in refrigerator in sealed containers. -The facility failed to ensure pureed food were not prepared at 8:00 AM and kept in oven until meal service started. -The facility failed to maintain 3 large ingredient storage bins free of white powder residual, food particles and grease build-up. -The facility failed to keep the kitchen equipment clean and free of food particles. -The facility failed to ensure the three-compartment sink sanitizing chemicals were within acceptable range. -The facility failed to ensure the Dishwashing Machine ' s temperature was within acceptable range. [...]
  6. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview, and record review ,the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection in 1 of 6 (500 Hall) hallways,1 soiled container (800 Hall) of 2 containers, and for 3 (Resident #74, #200 and Resident #128) of 29 reviewed for infection control. - The facility failed to ensure staff followed infection control practices when passing out meal trays during dining service. - The facility failed to ensure a soiled linen container was properly closed. - The facility failed to ensure that Resident #74 ' s urinary catheter was not touching the floor. - The facility failed to ensure that Resident #200 ' s urinary catheter was not touching the floor. [...]
  7. D
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 (Resident #43) of 2 residents reviewed for enteral feeding. -The facility failed to ensure that Resident #43 ' s HOB was maintained according to physician orders. This failure could place residents receiving enteral feedings at risk of aspiration (when food or liquid goes into the lungs or airway).
  8. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked storage area and to limit access to authorized personnel for 1 of 1 medication rooms reviewed for medication storage;and 1of 4 medication carts reviewed for medication storage and handling of medications in accordance with manufacturers' specifications. -The facility failed to ensure nurses did not store their personal belongings in the medication room. -The facility failed to date Glucometer Normal/High Control Solutions and Glucose Test Strips when opened according to manufacturer recommendations in the 600 Hall. These failures could affect residents that received medications from the facility.
  9. D
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide chopped meat for one (Resident #69) of 26 residents reviewed food prepared in a form to meet individual needs. 1. The facility failed to ensure Resident #69 was served chicken nuggets of the prescribed consistency. 2. The facility failed to ensure Resident #69 was assessed quarterly for changes in chewing and swallowing ability. These failures placed residents who received chopped foods at risk of inadequate nutrition and weight loss.
  10. D
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 14, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 (Resident #301 and Resident# 33) of 2 residents observed for environment. The facility failed to ensure Resident #301 and Resident #33, who were on oxygen in Rooms 808 & 409, had oxygen signs posted outside of their bedrooms. This failure could place residents on oxygen therapy at risk of harm and exposed to a fire hazard if staff and visitors are not aware of oxygen present.

Fire safety inspections

3 fire safety citations on file: 1 on April 9, 2026, 2 on January 31, 2025.

Every fire safety citation3 citations
  1. E
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · April 9, 2026 · Corrected (the home has a date of correction)
  2. E
    Install proper backup exit lighting.
    K 281 · January 31, 2025 · Corrected (the home has a date of correction)
  3. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · January 31, 2025 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeTexasUnited States
All nursing staff (RN, LPN and aides)3.713.393.86
Registered nurses0.460.430.69
All nursing staff on weekends3.262.983.42
Nurse aides2.30
Licensed practical nurses0.95
Nursing staff turnover (share who left in a year)39.7%55.3%45.8%
Registered nurse turnover42.9%54.6%42.9%
Administrators who left1

CMS expects 3.20 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.89 on weekdays and 3.26 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.36 in April to June 2025 to 3.71 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.710.463.893.26 0.0%0 of 90152
Oct to Dec 20253.530.473.742.97 0.1%0 of 92155
Jul to Sep 20253.490.423.702.95 0.1%0 of 92157
Apr to Jun 20253.360.363.552.88 0.0%0 of 91156
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Texas, Jan to Mar 20263.330.403.502.932.2%0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Texas

JobMedianMiddle halfEmployed
Texas, all employers
CNAs (nursing assistants)$18.03$16.97 to $20.7188,680
LPNs and LVNs$29.92$27.46 to $32.8957,560
Registered nurses$46.14$38.06 to $50.53271,380
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Ambrosio Guillen Texas State Veterans Home. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
Employed by
Usual shift
Do you get a shift differential?
Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeTexasUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
23.915.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.20.30.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.50.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.33.33.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
4.01.51.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
21.214.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
2.23.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
19.39.615.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
17.625.723.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
9.612.312.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.42.21.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.82.11.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Ambrosio Guillen Texas State Veterans Home's Medicare short-stay residents. How to read these, and what Medicare pays for.

Went home or back to the community

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 51.5% · Texas: 116 better, 50 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 17 eligible stays.

Potentially preventable readmissions

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 10.7% · Texas: 0 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 24 eligible stays.

Infections that led to a hospital stay

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 7.1% · Texas: 4 better, 11 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 14 eligible stays.

Self-care and mobility at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas57.3% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 18 residents counted.

Falls with major injury

0.0% this home

Median of homes: Texas0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 24 residents counted.

New or worsened pressure ulcers

0.0% this home

Median of homes: Texas1.3% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 24 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 1 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: STATE OF TEXAS VETERANS LAND BOARD. CMS links this home to Texvet, a group of 9 nursing homes averaging 3 stars overall.

NameRoleTypeShareSince
Berkely, JohnW-2 managing employeeIndividual03/01/2018
Elledge, MatthewW-2 managing employeeIndividual12/31/2017
McLemore, WilliamW-2 managing employeeIndividual10/16/2014
McLemore, WilliamCorporate officerIndividual12/16/2014
Care Inns of Texas-Temple LtdOperational/managerial controlOrganization03/01/2018
Texas Vsi, LLCOperational/managerial controlOrganization03/01/2018
Touchstone Veterans Management, LtdOperational/managerial controlOrganization12/05/2014
Biggs, WilliamOperational/managerial controlIndividual03/01/2018
McBride, MichaelOperational/managerial controlIndividual03/01/2018
McCrary, JaniceOperational/managerial controlIndividual03/01/2018
McLemore, WilliamOperational/managerial controlIndividual12/05/2014

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. When is the care plan meeting, and can family attend it?Inspectors cited 9 problems in this area, most recently on April 9, 2026: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 8 problems in this area, most recently on April 9, 2026: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 7 problems in this area, most recently on April 9, 2026: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
  4. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 6 problems in this area, most recently on April 9, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
  5. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

Texas contacts for a concern about a nursing home

These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.

Common questions

What is Ambrosio Guillen Texas State Veterans Home's Medicare star rating?
CMS rates Ambrosio Guillen Texas State Veterans Home 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Ambrosio Guillen Texas State Veterans Home get at its last inspection?
8 health deficiencies at the standard inspection on April 9, 2026. The Texas average is 9.4.
Has Ambrosio Guillen Texas State Veterans Home been fined?
CMS lists no fines in the last three years.
Does Ambrosio Guillen Texas State Veterans Home accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Ambrosio Guillen Texas State Veterans Home?
CMS lists 11 owners and managers, and links the home to Texvet. Legal business name: STATE OF TEXAS VETERANS LAND BOARD.

Sources

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