Ambrosio Guillen Texas State Veterans Home

In the surveyor’s words

From the most serious findings on record at Ambrosio Guillen Texas State Veterans Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF677Apr 9, 2026

  Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 14 residents (Resident #63, Resident #65, and Resident #148) reviewed for ADL care.- The facility failed on 04/2026 to ensure Resident #63's, Resident #65's and Resident #148's fingernails were clean and trimmed.This failure could place residents who required assistance with ADLs at risk for unmet care needs.Findings include: Resident #63 Record review of Resident #63's admission Sheet dated 04/08/26 revealed a [AGE] year-old male with admission date 07/31/2020. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2026

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed on 04/07/2026 to ensure leftover food was properly covered and sealed in the walk-in refrigerator.-The facility failed on 04/07/2026 to ensure dietary staff maintained proper hygiene, as evidenced by a torn hairnet that allowed hair exposure during meal handling.-The facility failed on 04/07/2026 to ensure dietary staff practiced hand hygiene and glove changes per the facility policy after their hands became contaminated. […]

• No harm, potential for more than minimal, patternF583Mar 19, 2026

  Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 9 residents (Resident #1 Resident #2, Resident #3, and Resident #4) reviewed for dignity.-The facility failed on 3/18/2026 to provide glucose reading for Resident #1, Resident #2, Resident #3, and Resident #4 in a private setting.-The facility failed on 3/18/2026 to provide insulin injection for Resident #1, Resident #2, Resident #3, and Resident #4 in a private setting.The deficient practice could affect residents by contributing to poor self-esteem, dignity issues, diminished quality of… […]

• No harm, potential for more than minimal, patternF880Mar 19, 2026

  Based on observation, interview, and record review the facility failed to maintain an infection prevention program designed to provide safe, sanitary, and prevent the development and transmission of communicable diseases and infections for 5 of 12 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for transmission-based precautions.-LVN G failed to perform hand hygiene and change gloves after disposing the dirty wound dressings, disposing his PPE gown, and before cleaning the wound, and applying the new wound dressing on 03/14/2026.-LVN G failed to secure his PPE gown before wound care and disposed of it without putting on a new one while providing wound care on 03/14/2026.-RN A failed on 3/18/2026 to practice proper hand hygiene during glucose… […]

• No harm, potential for more than minimal, patternF607Sep 15, 2025

  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. […]