Avir at Tierra Este
14300 Pebble Hills Blvd · El Paso, TX · 79938 · 9159559998
120 certified beds For profit - Limited Liability company Chain: Avir Health Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
RN staffing in the bottom 10% nationally
0.21 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
60% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.03 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.21 | 0.55–0.75 |
| Weekend hours / resident-day | 2.77 | ≈ weekday level |
| Nursing turnover / year | 60% | median 45% |
| Fines (3-yr window) | 7 · $31,752 |
Inspection citations (62 in the current record)
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Potential for harm · D January 15, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 20, 2026 · Resident Assessment and Care Planning
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Potential for harm · E January 15, 2026 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 20, 2026 · Nutrition and Dietary
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Potential for harm · E September 5, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 30, 2025 · Resident Rights
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Potential for harm · D September 5, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected September 30, 2025 · Resident Rights
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Potential for harm · D September 5, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · E September 5, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 30, 2025 · Quality of Life and Care
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Potential for harm · E September 5, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected September 30, 2025 · Quality of Life and Care
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Potential for harm · D September 5, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 30, 2025 · Pharmacy Service
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Potential for harm · E September 5, 2025
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 September 30, 2025 · Pharmacy Service
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Potential for harm · D September 5, 2025
Provide and implement an infection prevention and control program.
Corrected September 30, 2025 · Infection Control
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Potential for harm · F April 1, 2025 · found via complaint
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected April 9, 2025 · Nursing and Physician Services
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Potential for harm · D February 20, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 21, 2025 · Quality of Life and Care
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Potential for harm · D November 27, 2024 · found via complaint
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 November 29, 2024 · Quality of Life and Care
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Potential for harm · D August 2, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected August 7, 2024 · Resident Rights
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Potential for harm · D August 2, 2024
Reasonably accommodate the needs and preferences of each resident.
Corrected August 7, 2024 · Resident Rights
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Potential for harm · D August 2, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected August 7, 2024 · Resident Rights
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Potential for harm · D August 2, 2024
Keep residents' personal and medical records private and confidential.
Corrected August 7, 2024 · Resident Rights
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Potential for harm · E August 2, 2024
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected August 7, 2024 · Resident Rights
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Potential for harm · D August 2, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected August 7, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 2, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 7, 2024 · Quality of Life and Care
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Potential for harm · D August 2, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected August 7, 2024 · Quality of Life and Care
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Potential for harm · E August 2, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected August 7, 2024 · Pharmacy Service
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Potential for harm · D August 2, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected August 7, 2024 · Pharmacy Service
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Potential for harm · E August 2, 2024
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 August 7, 2024 · Pharmacy Service
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Potential for harm · E August 2, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected August 7, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 20, 2024 | Fine | $4,178 |
| February 12, 2024 | Fine | $3,798 |
| January 22, 2024 | Fine | $9,116 |
| January 8, 2024 | Fine | $2,279 |
| January 2, 2024 | Fine | $1,764 |
| December 11, 2023 | Fine | $3,174 |
| November 9, 2023 | Fine | $7,443 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 745038 · certified since June 6, 2023. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.