Ambrosio Guillen Texas State Veterans Home

Inspection findings

1. Apr 9, 2026 Health · 9 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected May 19, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected May 19, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 19, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected May 19, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 19, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 19, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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 May 19, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 19, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Jun 1, 2026 · CMS fire safety

2. Mar 19, 2026 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 1, 2026 · CMS health inspection

3. Feb 3, 2026 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Mar 13, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Mar 13, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Mar 13, 2026 · CMS health inspection

4. Nov 20, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 23, 2025 · CMS health inspection

5. Sep 15, 2025 Health · 4 findings
   • Not serious Scope/severity E Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Oct 24, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 24, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0726 Nursing and Physician Services Deficiencies

     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 Oct 24, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Oct 24, 2025 · CMS health inspection

6. Apr 3, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 25, 2025 · CMS health inspection

7. Jan 31, 2025 Health · 9 findings
   • Not serious Scope/severity E

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Mar 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0585 Resident Rights Deficiencies

     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 Mar 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Mar 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Mar 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Mar 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 15, 2025 · CMS fire safety

8. Nov 18, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Dec 20, 2024 · CMS health inspection

9. Jul 26, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     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 Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Aug 30, 2024 · CMS health inspection

10. May 31, 2024 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Jun 21, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Jun 21, 2024 · CMS health inspection

11. Apr 24, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

      Corrected May 22, 2024 · CMS health inspection

12. Dec 1, 2023 Health · 10 findings
    • Not serious Scope/severity E Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0693 Quality of Life and Care Deficiencies

      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 Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      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 Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0804 Nutrition and Dietary Deficiencies

      Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

      Corrected Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0805 Nutrition and Dietary Deficiencies

      Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

      Corrected Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jan 14, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0921 Environmental Deficiencies

      Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

      Corrected Jan 14, 2024 · CMS health inspection

Owners and managers (as published by CMS)

• BERKELY, JOHN — w-2 managing employee, NOT APPLICABLE, since 03/01/2018
• BIGGS, WILLIAM — operational/managerial control, NOT APPLICABLE, since 03/01/2018
• ELLEDGE, MATTHEW — w-2 managing employee, NOT APPLICABLE, since 12/31/2017
• MCBRIDE, MICHAEL — operational/managerial control, NOT APPLICABLE, since 03/01/2018
• MCCRARY, JANICE — operational/managerial control, NOT APPLICABLE, since 03/01/2018
• MCLEMORE, WILLIAM — corporate officer, NOT APPLICABLE, since 12/16/2014
• MCLEMORE, WILLIAM — operational/managerial control, NOT APPLICABLE, since 12/05/2014
• MCLEMORE, WILLIAM — w-2 managing employee, NOT APPLICABLE, since 10/16/2014
• CARE INNS OF TEXAS-TEMPLE LTD — operational/managerial control, NOT APPLICABLE, since 03/01/2018
• TEXAS VSI, LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2018
• TOUCHSTONE VETERANS MANAGEMENT, LTD — operational/managerial control, NOT APPLICABLE, since 12/05/2014