Ambrosio Guillen Texas State Veterans Home
9650 Kenworthy St, El Paso, TX 79924
Below federal staffing minimum — average inspection record.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
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0.42 ✗ Below federal minimum (0.55) |
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Health Deficiencies
Violations found during federal inspections over the last 3 years.
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13 |
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★★★ (5/5)
Staffing: ★★★☆☆ (3/5)
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NursingHomeGrade Score
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56/100 |
Data last updated: April 12, 2026
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
Most recent inspection (November 20, 2025)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 23, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2025
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.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2025
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2025
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2025
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2026
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 13, 2026
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2025
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2025
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 15, 2025
Inspection cycle 2 (December 1, 2023)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 22, 2024
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 30, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 30, 2024
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 20, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 30, 2024
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2024
Inspection cycle 3 (October 6, 2022)
Keep all essential equipment working safely.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 18, 2022
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