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Nursing HomeMedicaid Investigative

Avir at Tierra Este

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

14300 Pebble Hills Blvd., El Paso, TX 79938120 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.4/5

based on 190 Google reviews

5
4
3
2
1
Avir at Tierra Este Nursing Home in El Paso, TX — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (11 vs median 8.0)
  • High staff turnover (69%)
  • High RN turnover (100%)

Bottom 25% in Texas · Critically understaffed (RN) · Worst in AVIR HEALTH GROUP chain · $31,752 in fines

Source: Medicare data

What this means for your family

This facility is an excellent choice for those prioritizing a clean, modern, and aesthetically pleasing environment with great rehab services. However, families should closely monitor daily hygiene and medication administration, as several reviewers have noted serious lapses in care due to staffing shortages.

Google Reviews

Google Reviews

190 reviews on Google
AVIR AT TIERRA ESTE is frequently praised for its beautiful, modern, and exceptionally clean facility and its welcoming admissions process. While many families report high satisfaction with the nursing staff and physical therapy, there are serious, recurring reports of understaffing, neglect regarding hygiene, and issues with medication management.

Quality Themes

Tap a score for details
Food8.0Staff7.0Clean9.0Activities8.0Meds3.0MemoryN/AComms5.0ValueN/A

Strengths

  • Clean and modern facility
  • Professional and welcoming admissions staff
  • Effective physical therapy and rehab services
  • Friendly and attentive nursing staff

Concerns

  • Understaffing leading to delayed care and hygiene issues (mentioned by 5 reviewers)
  • Inconsistent medication management and clinical errors (mentioned by 2 reviewers)
  • High noise levels and lack of privacy in shared rooms (mentioned by 2 reviewers)
  • Difficulty with transportation coordination (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2344.62023(35)4.22024(53)4.32025(44)4.42026(23)

Distribution · 155 analyzed

5
116
4
15
3
1
2
5
1
18

How They Respond to Reviews

100%response rate
Good

The owner provides personalized responses that frequently use the reviewer's name and acknowledge specific details like staff members or facility cleanliness. For negative reviews, the owner uses a consistent professional template that denies the validity of the claims and provides a phone number for direct resolution.

Questions for Your Tour

  • 1Since the admissions team is known for being so welcoming, could you walk us through the specific steps for transitioning a loved one into a room here?
  • 2With the recent focus on improving clinical care, what specific new protocols have been put in place to ensure medication management is 100% accurate?
  • 3How does the nursing team manage care during busy shifts to ensure that hygiene needs and personal requests are never delayed?
  • 4We've heard great things about the physical therapy services; how often do residents participate in rehab or movement programs?
  • 5In the shared room settings, what steps are taken to help residents maintain their privacy and manage noise levels for better sleep?
  • 6What is the process for coordinating transportation if a resident needs to attend an outside medical appointment or family event?

Personalized based on this facility's data


Key Review Excerpts

The dietary manager was incredible! He made sure my gluten free meals were properly prepare

Rehab patient · 2023★★★★★

The facility is new, spotless, and has a lovely charm to it. Our appointment began with a tour of all the communal spaces.

Prospective resident's family · 2024★★★☆☆

My mother was there until she passed away. She was the one who told me 'Every single person of their stuff are extremely nice'.

Long-term resident's family · 2025★★★★★
Source: 190 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.21hrs
28%
Registered nurses for medical care
Total Nursing
3.03hrs
74%
All nurses + aides combined
Staff Turnover
60%
Lower is better (< 30% = good)
RN Turnover
100%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

7

measures

Worse Than Avg

9

measures

Mixed Results

1

measures

Long-Stay Residents
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility80.2%
Worse than Avg
Here
80.2%
US
95.5%
TX
98.0%
El paso
95.1%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility25.7%
Worse than Avg
Here
25.7%
US
15.4%
TX
9.4%
El paso
14.0%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility27.4%
Worse than Avg
Here
27.4%
US
19.5%
TX
18.4%
El paso
13.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility2.1%
Better than Avg
Here
2.1%
US
12.1%
TX
2.5%
El paso
4.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.1%
Better than Avg
Here
8.1%
US
15.3%
TX
14.9%
El paso
15.1%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility21.3%
Worse than Avg
Here
21.3%
US
19.4%
TX
14.2%
El paso
16.8%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility76.1%
Worse than Avg
Here
76.1%
US
81.8%
TX
89.2%
El paso
83.2%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility89.6%
Better than Avg
Here
89.6%
US
79.7%
TX
88.0%
El paso
82.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility5.1%
Worse than Avg
Here
5.1%
US
1.6%
TX
1.5%
El paso
2.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

10deficiencies
7penalties
Above state avg (9.1)
31 complaint-triggered
$31,752 in fines

This facility shows a concerning pattern with 73 deficiencies across 14 surveys, including numerous family complaints that triggered investigations. Most frequent problems involve infection control, medication management, and food safety - with food safety violations recurring without correction plans. Recent deficiencies from 2025-2026 remain uncorrected, and complaints continue into 2025 regarding nursing staffing and care planning, suggesting ongoing systemic issues that persist despite correction attempts.

Jan 15, 2026Complaint
2
0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0656Potential for harm · IsolatedCorrected

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.

Sep 5, 2025Routine
16
0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0761Potential for harm · PatternCorrected

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.

0041Potential for harm · PatternCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

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

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0911Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0656Potential for harm · IsolatedCorrected

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.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Apr 1, 2025Complaint
1
0727Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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.

Feb 20, 2025Complaint
1
0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Nov 27, 2024Complaint
1
0690Potential for harm · IsolatedCorrected

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.

Aug 2, 2024Routine
22
0921Potential for harm · WidespreadCorrected

Environmental Deficiencies

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

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0041Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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

0758Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · PatternCorrected

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.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0814Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0868Potential for harm · PatternCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0580Potential for harm · IsolatedCorrected

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.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Federal Penalties

Fine

Feb 20, 2024

$4,178

Fine

Feb 12, 2024

$3,798

Fine

Jan 22, 2024

$9,116

Fine

Jan 8, 2024

$2,279

Fine

Jan 2, 2024

$1,764

Fine

Dec 11, 2023

$3,174

Fine

Nov 9, 2023

$7,443

Ownership & Operations

Who Operates This Facility

Owner / Operator

West Wharton County Hospital District

Organization Type

for profit

Management Company

14300 PEBBLE HILLS BOULEVARD OPCO LLC

Administrator

SARA D HUCKINS

Chain Affiliation

Chain Name

Avir Health Group

Chain Size

117 facilities nationwide

Chain avg rating: 2.3/5 · Rank 64 of 90 (Worst)

Ownership & Management

Owners

East El Paso Healthcare Operations LLC

Owner (parent company) · Organization

Douglas, Lloyd

Owner (parent company)

Key personnel

Conquest Healthcare Management LLCManagerDouglas, LloydManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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