The Bartlett Skilled Nursing and Assisted Living

Nursing Home · El Paso, TX

CMS overall rating 1/5 Abuse citation For profit - Partnership

CMS certification number676457
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).

Contact & location

221 Bartlett Drive
El Paso, TX 79912
El Paso County
Phone
(915) 584-8438
ZIP code
79912 – all care providers

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Facility details

Certified beds
58
Residents per day
53.7 (93% occupied)
Ownership
For profit - Partnership
Legal name
Penan Retirement Centers Limited Partnership
Medicare certified since
November 2, 2018
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 1/5
State avg 2.6
Health inspections★★★★★ 2/5
State avg 2.8
Staffing★★★★★ 1/5
State avg 1.9
Quality measures★★★★★ 2/5
State avg 3.7
Long-stay quality★★★★★ 3/5
Short-stay quality★★★★★ 2/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.58 (state 3.39 · U.S. 3.86)
Registered nurses (RN)
0.15 (state 0.43 · U.S. 0.69)
Licensed practical nurses
1.47 (state 0.95 · U.S. 0.86)
Nurse aides
1.96 (state 2.00 · U.S. 2.32)
Weekend total
3.16 (state 2.98 · U.S. 3.42)
Nursing staff turnover
—
RN turnover
—

Inspections

Last standard inspection
August 22, 2025
Health deficiencies (last cycle)
12.0 (state 9.3 · U.S. 9.3)
From complaints
7
Citations on record (3 years)
37 health · 12 fire safety · includes actual harm
DateCitationSeverityStatus
2026-06-17 Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-06-18
2026-04-11 Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
F0627 · Resident Rights Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-04-30
2026-04-11 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-30
2026-04-11 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.
F0585 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-30
2025-08-22 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-25
2025-08-22 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-25
2025-08-22 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
F0945 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-25
2025-08-22 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-25
2025-08-22 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-25
2025-08-07 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2025-08-27
2025-08-07 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-27
2025-08-07 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-27
2025-03-13 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-14
2025-02-06 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F0694 · Quality of Life and Care Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-02-07
2025-02-06 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-02-07
2024-07-11 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
F0944 · Administration Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-08-01
2024-07-11 Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-26
2024-07-11 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.
F0758 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-12
2024-07-11 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-12
2024-07-11 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-12
2024-07-11 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-12
2024-07-11 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F0756 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-26
2024-07-11 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-26
2023-06-15 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 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.
F0758 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Dispose of garbage and refuse properly.
F0814 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Honor the resident's right to organize and participate in resident/family groups in the facility.
F0565 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Ensure residents have reasonable access to and privacy in their use of communication methods.
F0576 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03
2023-06-15 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-03

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

2 penalties in the last three years, including $34,613 in fines.

DateTypeAmount
2026-04-11Fine$13,065
2025-08-07Fine$21,548

Ownership & management

NameRoleSince
Douglas G Pendergras SR Estate (organization)5%+ Direct Ownership Interest · 50%
Penan Retirement INC. (organization)5%+ Direct Ownership Interest
Pendergras, Don (individual)5%+ Direct Ownership Interest · 50%
Douglas G Pendergras SR Estate (organization)5%+ Security Interest · NOT APPLICABLE
Annabi, Michael (individual)Administrator · NOT APPLICABLE
Douglas G Pendergras SR Estate (organization)Administrator · NOT APPLICABLE
Perkins, Michael (individual)Administrator · NOT APPLICABLE
Penan Retirement INC. (organization)General Partnership Interest · NOT APPLICABLE
Pendergras, Don (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of The Bartlett Skilled Nursing and Assisted Living?

The Bartlett Skilled Nursing and Assisted Living has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.

How many beds does The Bartlett Skilled Nursing and Assisted Living have?

It has 58 certified beds and cares for about 54 residents per day.

Has The Bartlett Skilled Nursing and Assisted Living been fined?

Yes. CMS lists 2 penalties totaling $34,613 in the last three years.

What is the phone number of The Bartlett Skilled Nursing and Assisted Living?

(915) 584-8438. The facility is located at 221 Bartlett Drive, El Paso, TX 79912.

Other nursing homes in El Paso

Compare all nursing homes in El Paso, TX →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.