Ambrosio Guillen Texas State Veterans Home
Owned by: Government - State
Safety Pulse
AI-GENERATED FAMILY INSIGHTS
RED FLAG: Multiple instances of failure to prevent abuse, neglect, and theft, indicating systemic issues with resident protection.
RED FLAG: Deficiencies in accident prevention and adequate supervision suggest a potentially hazardous environment for residents.
RED FLAG: Concerns regarding staff competency and medication errors raise serious questions about the quality and safety of care provided.
Note: This summary is generated from recently documented safety inspections and citations.
Regional Context
313% more violations than city average
Source: 3-year federal inspection history (CMS.gov)
Quick Stats
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Violation History
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe and appropriate respiratory care for a resident when needed.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
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.
Ensure that residents are free from significant medication errors.
Ensure that residents are free from significant medication errors.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Reasonably accommodate the needs and preferences of each resident.
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.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe and appropriate respiratory care for a resident when needed.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure each resident receives an accurate assessment.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Reasonably accommodate the needs and preferences of each resident.
Reasonably accommodate the needs and preferences of each resident.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Ensure each resident receives an accurate assessment.
Ensure each resident receives an accurate assessment.
PASARR screening for Mental disorders or Intellectual Disabilities
PASARR screening for Mental disorders or Intellectual Disabilities
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.
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.
Post nurse staffing information every day.
Post nurse staffing information every day.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
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.
Ensure medication error rates are not 5 percent or greater.
Ensure medication error rates are not 5 percent or greater.
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.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Keep all essential equipment working safely.
Keep all essential equipment working safely.
Regional Safety Benchmarking
313% more citations than local average
"Comparative analysis is essential for identifying systemic neglect. Our benchmarks are updated monthly using raw CMS files."
Full Evidence Dossier
Documented history of neglect citations, staffing failures, and ownership risk profiles. Perfect for families, legal preparation, or professional due diligence.
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