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The Bartlett Skilled Nursing and Assisted Living
221 Bartlett Drive, El Paso, TX 79912 · CMS Certification Number (CCN) 676457
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 37 in the last 3 inspection cycles (0 immediate jeopardy, 2 actual harm, 10 from complaints)
- Fire safety citations
- 12
- Fines (last 3 years)
- 2 fines, total $34,928
- Payment denials
- 0
- Most recent standard inspection
- August 22, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | August 22, 2025 | 9 | 5 | 4 |
| Cycle 2 | July 11, 2024 | 14 | 8 | 6 |
CMS weighted health inspection score: 77 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
37 health citations across 8 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 17, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/18/2026 |
April 11, 2026: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/30/2026 |
| G | F-0627 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/30/2026 |
| D | F-0585 | 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. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/30/2026 |
August 22, 2025: 5 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/25/2025 |
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/25/2025 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/25/2025 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/25/2025 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/25/2025 |
August 7, 2025: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/27/2025 |
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/27/2025 |
| G | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/27/2025 |
March 13, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/14/2025 |
February 6, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/07/2025 |
| E | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/07/2025 |
July 11, 2024: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/01/2024 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/12/2024 |
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/26/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/12/2024 |
| E | F-0758 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/12/2024 |
| D | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/26/2024 |
| E | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/26/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/12/2024 |
June 15, 2023: 14 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| E | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| E | F-0758 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| E | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/03/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
12 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 08/22/2025 | E | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 10/28/2025 |
| 08/22/2025 | E | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 10/28/2025 |
| 08/22/2025 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 10/28/2025 |
| 08/22/2025 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/28/2025 |
| 08/22/2025 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/28/2025 |
| 08/22/2025 | F | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 10/28/2025 |
| 08/22/2025 | F | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 10/28/2025 |
| 07/11/2024 | F | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/18/2024 |
| 07/11/2024 | F | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/31/2024 |
| 06/15/2023 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 07/28/2023 |
| 06/15/2023 | E | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 08/10/2023 |
| 06/15/2023 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/28/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| April 11, 2026 | Fine | $13,065 | — |
| August 7, 2025 | Fine | $21,863 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.58 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.15 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.47 | Not published | Not published |
| Nurse aide hours per resident per day | 1.96 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.16 | Not published | Not published |
| RN hours per resident per day, weekends | 0.15 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data not submitted or invalid for calculating turnover. | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
| Administrators who have left | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Penan Retirement Centers Limited Partnership
- Ownership type
- For profit - Partnership
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 58
- Average residents per day
- 53.7
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- November 2, 2018
- County/parish
- El Paso
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
9 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| DOUGLAS G PENDERGRAS SR ESTATE | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 50% | undefined undefined, NaN |
| PENAN RETIREMENT INC. | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| PENDERGRAS, DON | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Individual | 50% | undefined undefined, NaN |
| DOUGLAS G PENDERGRAS SR ESTATE | 5% OR GREATER SECURITY INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| PENDERGRAS, DON | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PENAN RETIREMENT INC. | GENERAL PARTNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| DOUGLAS G PENDERGRAS SR ESTATE | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ANNABI, MICHAEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PERKINS, MICHAEL | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: The Bartlett Skilled Nursing and Assisted Living. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.