Avir at Tierra Este

In the surveyor’s words

From the most serious findings on record at Avir at Tierra Este, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690May 18, 2026

  Based interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #1) six residents reviewed for catheter care.- The facility failed to ensure LVN A appropriately monitored and assessed Resident #1 following catheter removal, responded timely to repeated reports of urinary retention, and ensured proper catheter reinsertion resulting in prolonged urinary obstruction, traumatic catheterization, septic shock, hemodynamic instability, and ICU hospitalization.- The facility failed to ensure LVN K removed Resident #1's catheter on 03/20/26 during the day shift when Bladder Training was completed according to… […]

• Actual harm, isolatedF656Nov 9, 2023

  Based on interview and record review the facility failed to implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: CNA B failed to follow Resident #1's comprehensive person-centered care plan to use a hoyer lift when transferring Resident #1 and instead used a one-person transfer (Get the surface the patient is moving to and the surface the patient is moving from as close as you can while still leaving enough room for the two of you to move freely). […]

• Actual harm, isolatedF689Nov 9, 2023

  Based on interview and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 4 residents reviewed for accidents. The facility failed to ensure CNA B used the hoyer lift to transfer Resident #1 knowing Resident #1 required the use of a hoyer lift for transfers, instead using the one person transfer technique (Get the surface the patient is moving to and the surface the patient is moving from as close as you can while still leaving enough room for the two of you to move freely) to prevent injury. This was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. […]

• No harm, potential for more than minimal, widespreadF727Apr 1, 2025

  Based on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON reviewed for DON coverage. The facility failed to have a full-time DON as of 03/23/25. This failure could place residents at risk of lack or nursing oversight and a higher level of care. Findings include: Record review of staff hours Employee Timecard Report, from 03/16/25 through 03/31/25, indicated there was no DON in the facility from 03/20/25 through 03/31/25. On 04/01/25 there was no DON. […]

• No harm, potential for more than minimal, widespreadF921Aug 2, 2024

  Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in four of four halls reviewed for environmental conditions. -The facility failed to clean facility over the weekend of 07/28/24 due to not having sufficient personal to clean the resident rooms and common areas. -The facility failed to maintain the environment free of accident hazards. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. […]