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Ambrosio Guillen Texas State Veterans Home
9650 Kenworthy St, El Paso, TX 79924 · CMS Certification Number (CCN) 676060
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 43 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 27 from complaints)
- Fire safety citations
- 3
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- April 9, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | April 9, 2026 | 18 | 8 | 10 |
| Cycle 2 | January 31, 2025 | 24 | 7 | 17 |
CMS weighted health inspection score: 108 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
43 health citations across 12 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
April 9, 2026: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
| D | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
| E | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
| D | F-0656 | 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 | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/19/2026 |
March 19, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/01/2026 |
| E | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/01/2026 |
February 3, 2026: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Complaint | Deficient, Provider has date of correction Corrected 03/13/2026 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/13/2026 |
| D | F-0580 | 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 | Complaint | Deficient, Provider has date of correction Corrected 03/13/2026 |
November 20, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/23/2025 |
September 15, 2025: 4 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/24/2025 |
| D | F-0726 | 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 | Complaint | Deficient, Provider has date of correction Corrected 10/24/2025 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/24/2025 |
| E | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/24/2025 |
April 3, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/25/2025 |
January 31, 2025: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/15/2025 |
| E | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/15/2025 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/15/2025 |
| E | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/15/2025 |
| E | F-0585 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/15/2025 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/15/2025 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/15/2025 |
November 18, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Complaint | Deficient, Provider has date of correction Corrected 12/20/2024 |
July 26, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Complaint | Deficient, Provider has date of correction Corrected 08/30/2024 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/30/2024 |
| D | F-0690 | 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 | Complaint | Deficient, Provider has date of correction Corrected 08/30/2024 |
May 31, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | 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 | Complaint | Deficient, Provider has date of correction Corrected 06/21/2024 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/21/2024 |
April 24, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/22/2024 |
December 1, 2023: 10 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/14/2024 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| D | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| D | F-0761 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| D | F-0693 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| E | F-0656 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/14/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
3 fire safety citations across 2 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 04/09/2026 | E | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/01/2026 |
| 01/31/2025 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/15/2025 |
| 01/31/2025 | E | K-0281 | Install proper backup exit lighting. Egress Deficiencies | Deficient, Provider has date of correction Corrected 03/15/2025 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.71 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.46 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.95 | Not published | Not published |
| Nurse aide hours per resident per day | 2.3 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.26 | Not published | Not published |
| RN hours per resident per day, weekends | 0.34 | Not published | Not published |
| Total nursing staff turnover (%) | 39.7 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 42.9 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- State of Texas Veterans Land Board
- Ownership type
- For profit - Corporation
- Chain
- Texvet (9 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 160
- Average residents per day
- 151.6
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- August 3, 2005
- County/parish
- El Paso
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
11 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| BERKELY, JOHN | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ELLEDGE, MATTHEW | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCLEMORE, WILLIAM | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCLEMORE, WILLIAM | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CARE INNS OF TEXAS-TEMPLE LTD | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TEXAS VSI, LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TOUCHSTONE VETERANS MANAGEMENT, LTD | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BIGGS, WILLIAM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCBRIDE, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCCRARY, JANICE | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCLEMORE, WILLIAM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Ambrosio Guillen Texas State Veterans Home. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.