Cycle 1
Health 2025-01-31 · Fire 2025-01-31
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
El Paso, TX
Ambrosio Guillen Texas State Veterans Home
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
9650 Kenworthy St, El Paso, TX
(915) 751-0967
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
157
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Texvet
Operator or chain grouping
Approved since
2005-08-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,083
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.91
Composite VBP score used to determine payment impact.
Payment multiplier
1.0063
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.45
Baseline 40.60% · Performance 37.31% · Measure score 6.45 · Achievement 6.45 · Improvement 1.59
Adjusted total nurse staffing
3.93
Baseline 4.01 hours · Performance 4.20 hours · Measure score 3.93 · Achievement 3.93 · Improvement 0.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 55% |
95.27%
40.3 pts worse
|
Numerator 11 · Denominator 20 |
| Falls with major injury | 5% |
0.77%
4.2 pts worse
|
Numerator 1 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 201 |
| Staff flu vaccination coverage | 34.16% |
42%
7.8 pts worse
|
Numerator 69 · Denominator 202 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
97.1%
6.9 pts worse
|
93.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 83.7% · Q3 94.2% · Q4 95.5% · 4Q avg 90.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
97.9%
2.2 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.3%
0.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.6% · Q3 2.6% · Q4 1.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
2.7%
0.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 2.1% · Q3 1.5% · Q4 3.5% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
3.3%
1.3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.9% · Q3 1.4% · Q4 1.4% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
18.9%
4.5 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 14.5% · Q3 15.3% · Q4 11.6% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
10.8%
2.6 pts worse
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 12.1% · Q3 17.6% · Q4 12.5% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.5% |
15.4%
2.1 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 20.5% · Q3 29.5% · Q4 11.2% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
16.1%
4.3 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 18.5% · Q3 27.6% · Q4 26.6% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
15.0%
2.7 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 9.7% · Q3 12.5% · Q4 15.3% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.2%
1.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.3% · Q3 2.6% · Q4 2.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.4% |
89.7%
29.3 pts worse
|
81.7%
21.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 69.0% · Q3 68.2% · Q4 63.0% · 4Q avg 60.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
1.5%
3.4 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
88.0%
8 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
13 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-31
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-23
E · Potential for more than minimal harm
2025-09-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-24
E · Potential for more than minimal harm
2025-09-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-15
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-04-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-25
E · Potential for more than minimal harm
2025-01-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-01-31
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-01-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-01-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-01-31
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-01-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-01-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-15
D · Potential for more than minimal harm
2024-11-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-07-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-05-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-04-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-22
E · Potential for more than minimal harm
2023-12-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-12-01
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-12-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-12-01
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-12-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-14
E · Potential for more than minimal harm
2022-10-06
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-06
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-06
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-06
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-11-18
Penalties and ownership
What sits behind the stars
Ownership
Berkely, John
W-2 Managing Employee · Individual
Biggs, William
Operational/Managerial Control · Individual
Care Inns Of Texas-Temple Ltd
Operational/Managerial Control · Organization
Elledge, Matthew
W-2 Managing Employee · Individual
Mcbride, Michael
Operational/Managerial Control · Individual
Mccrary, Janice
Operational/Managerial Control · Individual
Mclemore, William
Operational/Managerial Control · Individual
Mclemore, William
Corporate Officer · Individual
Mclemore, William
W-2 Managing Employee · Individual
Texas Vsi, LLC
Operational/Managerial Control · Organization
Touchstone Veterans Management, Ltd
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Avir At Patriot
El Paso, TX
1-star overall rating with 2-star inspections with $38,235 in total fines with 18 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Los Arcos Del Norte Care Center
El Paso, TX
2-star overall rating with 2-star inspections with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Mountain Villa Nursing Center
El Paso, TX
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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