Ambrosio Guillen Texas State Veterans Home
Ambrosio Guillen Texas State Veterans Home in El Paso, TX — inspection on September 15, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ambrosio Guillen Texas State Veterans Home
9650 Kenworthy St El Paso, TX 79924
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ambrosio Guillen Texas State Veterans Home
9650 Kenworthy St El Paso, TX 79924
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ambrosio Guillen Texas State Veterans Home
9650 Kenworthy St El Paso, TX 79924
SUMMARY STATEMENT OF DEFICIENCIES
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.