The Bartlett Skilled Nursing and Assisted Living
221 Bartlett Drive, El Paso, TX 79912 · El Paso County · 58 certified beds · avg 54 residents/day · certified since Nov 2, 2018
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Apr 11, 2026 · F-0627 · triggered by a complaint
The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.
Why it matters: A rushed or poorly planned move can leave a resident somewhere that can't meet their needs.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 30, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 7, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 27, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 17, 2026 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Apr 11, 2026 | ▲ G · Actual harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Apr 11, 2026 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Apr 11, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Aug 22, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 22, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 22, 2025 | E · Potential for harm, repeated | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. |
| Aug 22, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 22, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 7, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Aug 7, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Feb 6, 2025 | E · Potential for harm, repeated | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Feb 6, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jul 11, 2024 | F · Potential for harm, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 14 | 0 | E |
| 2024 | 8 | 0 | F |
| 2025 | 11 | 1 | G ▲ |
| 2026 | 4 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $34,613.
| Date | Type | Amount / length |
|---|---|---|
| Apr 11, 2026 | Fine | $13,065 |
| Aug 7, 2025 | Fine | $21,548 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.39 | 3.46 | 3.95 | top 44% in Texas; bottom 31% in the U.S. |
| Registered Nurse hours | 0.14 | 0.44 | 0.69 | bottom 2% in Texas; bottom 1% in the U.S. |
| Weekend total nurse staffing | 3.00 | 3.04 | 3.50 | top 42% in Texas; bottom 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.15 | 0.34 | 0.48 | bottom 9% in Texas; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.3 | 45.8 | — |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.58, RN 0.15, weekend 3.16. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
For profit - Partnership
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Douglas G Pendergras Sr Estate | Organization | 5% or Greater Direct Ownership Interest | 50% | 03/20/2018 |
| Penan Retirement INC. | Organization | 5% or Greater Direct Ownership Interest | — | 01/01/2018 |
| Pendergras, Don | Individual | 5% or Greater Direct Ownership Interest | 50% | 01/01/2018 |
| Annabi, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2018 |
| Douglas G Pendergras Sr Estate | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/20/2018 |
| Douglas G Pendergras Sr Estate | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2018 |
| Penan Retirement INC. | Organization | General Partnership Interest | NOT APPLICABLE | 01/01/2018 |
| Pendergras, Don | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2018 |
| Perkins, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How are staff trained on infection control, and how often is that training refreshed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| White Acres Wellness & Rehabilitation | 0.6 mi | El Paso, TX | ★★☆☆☆ | 2/5 | |
| Franklin Heights Nursing & Rehabilitation | 1.4 mi | El Paso, TX | ★☆☆☆☆ | 1/5 | |
| Avir at el Paso | 3.1 mi | El Paso, TX | ★★☆☆☆ | 1/5 | |
| Mountain View Health & Rehabilitation | 5.5 mi | El Paso, TX | ★☆☆☆☆ | 1/5 | |
| Grace Pointe Wellness Center | 5.5 mi | El Paso, TX | ★☆☆☆☆ | 1/5 | |
| Mountain Villa Nursing Home | 6.9 mi | El Paso, TX | ★★★★☆ | 4/5 | |
| Ambrosio Guillen Texas State Veterans Home | 8.8 mi | El Paso, TX | ★★☆☆☆ | 2/5 | |
| Nazareth Living Care Center | 9.0 mi | El Paso, TX | ★★☆☆☆ | 2/5 | |
| Avir at Patriot | 10.1 mi | El Paso, TX | ★☆☆☆☆ | 1/5 | |
| Los Arcos Del Norte Care Center | 10.8 mi | El Paso, TX | ★☆☆☆☆ | 2/5 | |
| St. Teresa Nursing & Rehab Center | 13.8 mi | El Paso, TX | ★☆☆☆☆ | 2/5 | |
| Edgemere Estates | 15.1 mi | El Paso, TX | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676457.