Ambrosio Guillen Texas State Veterans Home

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based 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. The findings included:-Record review of facility's policy undated on Abuse, Neglect and Exploitation revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The components of the facility abuse prohibition plan include Screening-Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Screening may be conducted by the facility itself, third-party agency or academic institution. The facility will maintain documentation of proof that the screening occurred. -An interview and record review on 09/12/25 at 3:59 p.m., with the HR Resource Assistant, revealed CNA A was hired on 03/26/24 and the last EMR/NAR screening was completed on 03/20/2024. She said, We do not have any other EMR/NAR screening in the CNA's employee file to show that the annual EMR/NAR screening was completed according to facility policy. She said EMR/NR screening should be completed upon hire and annually. -An interview and record review on 09/12/25 at 4:04 p.m., with the HR Resource Assistant, revealed CNA B was hired on 05/01/18 and the last EMR/NAR screening was completed on 01/31/24. She said, We do not have any other EMR/NAR screening in the CNA's employee file to show that the annual EMR/NAR screening was completed according to facility policy. -During an interview and record review on 09/15/25 at 9:59 a.m., with the HR Business Partner, confirmed annual EMR/NAR screenings had not been completed on CNA A and CNA B. She said, EMR/NAR checks should be completed upon hire and annually according to facility policy.-During an

interview on 09/15/25 at 11:30 a.m., with the Administrator in the presence of HR Business Partner revealed, EMR/NAR checks should be completed upon hire and annually according to facility's policy and best practice.

Residents Affected - Some

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ambrosio Guillen Texas State Veterans Home

9650 Kenworthy St El Paso, TX 79924

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

an interview on 9/12/25 at 3:23 pm, the DOR stated PT and OT completed evaluations to determine their need and this would take about 30 minutes. He stated the bars were meant to assist with bed mobility and transfers for ADLs. He stated the new beds were installed about two weeks earlier. He stated approximately 71 evaluations had been completed, a little less than half of the residents. Some residents did not yet have bars because the assist bars were not available. He stated once evaluations were complete, physicians had to approve the orders, including those for enablers.During a follow up interview on 9/12/25 at 4:16 pm, the DON stated Resident #12 was still pending evaluation. She stated she had been told the therapy evaluations took about 30 minutes but had seen little progress in three weeks. During an interview on 9/15/25 at 9:34 am, the Administrator stated clinical leadership, unit managers, and DONs were responsible for prevention, call light placement, and ensuring staff were aware of fall risks. He stated post-fall risk meetings were held to identify causes and implement interventions such as footwear, low beds, and call lights. He stated he was familiar with Resident #2, describing him as paralyzed and later confused. He stated a fall mat was in place, the bed was in the lowest position, and although a call light was expected to be within reach, it could not be seen in the picture. He stated if the call light was thrown off the bed, frequent rounding should have ensured it was replaced. He stated the bedside table could obstruct pathways unless specifically care planned to be removed. Regarding assist bars, he stated this was a new process with the new beds and therapy assessments were pending. He stated the facility already had the bars but had not made progress on installations. He stated frequent rounding and call light placement were

the main interventions, though ideally the bars would enhance independence.Record review of the facility's Fall Prevention and Reduction Program policy not dated revealed in part A fall is defined as the act of unintentionally coming to rest on the ground, floor, or other lower level (e.g., onto a bed, chair, or bedside mat) but not as a result of an overwhelming external force (e.g., a resident pushes another resident). The fall may be witnessed, reported by the resident or an observer, or identified when a resident is observed on

the floor or ground and can occur anywhere. A near miss or an episode where a resident lost his or her balance and almost fell is also considered a fall, as well as a fall that does not result in injury. Individualized approaches may include, but are not limited to: evaluating the resident for recent change in medication; evaluating the resident for changes (mental/physical); therapy referral for evaluation; toileting plan to include

before meals and bedtime; use of bed and chair alarms; non-restrictive Velcro alarming seatbelt; protective equipment such as non-skid material to wheelchair or anti-tippers; non-skid socks; properly fitted shoes; bed in low position; bed on floor if feasible; bed against the wall; defined perimeter mattress; use of side rails to aid in bed mobility and to define bed perimeter; and equipment to aid with access to items in room.Record review of the facility's Side Rail/ Bed Rails policy not dated read in part Purpose: To utilize a person-centered approach when determining the use of side rails/bed rails and enhance resident's mobility and functional independence. Procedure: Side rail screen to be completed prior to use of side rail(s) which will address alternatives attempted and how those alternatives failed to meet the resident's assessed needs. Facility will assess if the side rail(s) meets the definition of a restraint. Refer to restraint screen as indicated. Review the risk/benefits and reason for the use of side rail(s) with the resident and/or resident representative. Obtain informed consent prior to installation/use of side rail(s). Use of side rail will be demonstrated to the resident/resident representative.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ambrosio Guillen Texas State Veterans Home

9650 Kenworthy St El Paso, TX 79924

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

RN Supervisor G and LVN Unit Manager F informed me when they called me on that day, to let me know that insulins could not be administered in the dining room. He said, he had not followed the technique on insulin administration like he was trained to do in nursing school. I know that the injection site needs to be cleaned prior to administering the injections. He said he was also trained in nursing school not to administer insulin through the clothes. He said, this could place the resident at risk for infection. -During an interview

on 09/09/25 at 1:53 PM, with Restorative CNA B revealed, she had reported to RN G who was the week-end Supervisor on that weekend that she had seen RN C inject insulin to a resident in the main dining room through the clothing, and that RN C was passing by the resident and did not tell the resident he was going to give him an insulin injection and just poked the resident with the needle through his shirt. She said the resident was startled when RN C had done this to him. I don't think that what RN C did to the resident was right, because he had not cleaned the area on the arm prior to injecting the insulin to the resident, and that placed the resident at risk for infection. This happened more than a month ago on the weekend, and I do not remember who the resident was. I later followed up with RN G, to see what had been done about my concern and all she said was that she had reported this to the DON. -During an

interview on 09/09/25 at 2:29 PM, with the DON revealed, she was not aware that Restorative CNA B had reported to RN Supervisor G that she had seen RN C inject a resident through his T-Shirt in the main dining room. The DON said The RN Supervisor G should have reported this to me or to RN ADON E and LVN Unit Manager F right away, to immediately address this concern to prevent it from reoccurring. This practice could place the resident at risk of infection. -During an interview and record review on 09/12/25 at 11:30 AM, with the DON revealed the facility did not have a Skills Checklist on Insulin Administration for the licensed staff. She informed the state surveyor she had found a Skills Checklist on Insulin Administration in one of the facility's Manuals that she was going to start using to check licensed staff on Insulin Medication Administration. She said the checklist documented, to select an appropriate injection site, free from edema, induration, tenderness, or skin irritation. Cleanse site with alcohol swab beginning at center of site and rotating outward approximately 2 inches. Allow skin to dry completely; do not fan or blow on site. With non-dominant hand, spread skin across injection site or pinch skin around injection site. Inform resident he/she will feel a slight pinch, pressure, or stinging sensation as the insulin is injected. She said, This will ensure licensed staff do not inject insulin over the clothes without cleaning the injection site, prior to administering the insulin. She said she was still looking for a policy & procedure on insulin administration and would provide the state surveyor a copy of the policy if she found one. The surveyor requested a copy of Nursing Policy & Procedures on Injection Administration. The DON did not provide the requested document before exit. The surveyor requested a copy of Pharmacy Policy & Procedures on Injection Administration. The DON did not provide the requested document before exit. Review of the facility's policy and procedures on Medication Administration revised July 1, 2025, revealed administer medications as ordered in accordance with manufacturer specifications. According to Manufacturer's specifications obtained on 09/10/25 at https://www.novo-pi.com Subcutaneous injection: inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ambrosio Guillen Texas State Veterans Home

9650 Kenworthy St El Paso, TX 79924

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)

Federal health inspectors cited Ambrosio Guillen Texas State Veterans Home in El Paso, TX for a deficiency under regulatory tag F-F0760 during a complaint investigation conducted on 2025-09-15.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of Ambrosio Guillen Texas State Veterans Home.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-24.