01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-22 | 12 | 2025-08-22 | 7 |
| Cycle 2 | 2024-07-11 | 11 | 2024-07-11 | 2 |
| Cycle 3 | 2023-06-15 | 14 | 2023-06-15 | 3 |
CMS CCN 6764572026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
The Bartlett Skilled Nursing And Assisted Living
221 Bartlett Drive · El Paso, TX 79912 · El Paso County
Certified beds58CMS provider file
Recent citation rows49current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
49 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-17 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2026-06-18 · complaint2026-04-11 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-04-30 · complaint2026-04-11 · HEALTHF0627Severity G · isolated actual harm
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Correction field: Deficient, Provider has date of correction · 2026-04-30 · complaint2026-04-11 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-30 · complaint2025-08-22 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-10-282025-08-22 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2025-10-282025-08-22 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-08-252025-08-22 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-08-252025-08-22 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-08-252025-08-22 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-252025-08-22 · HEALTHF0945Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Correction field: Deficient, Provider has date of correction · 2025-08-252025-08-22 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-10-282025-08-22 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-10-282025-08-22 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-10-282025-08-22 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-10-282025-08-22 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2025-10-282025-08-07 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-08-27 · complaint2025-08-07 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-08-27 · complaint2025-08-07 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-08-27 · complaint2025-03-13 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-03-14 · complaint2025-02-06 · HEALTHF0694Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-02-07 · complaint2025-02-06 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-07 · complaint2024-07-11 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2024-07-312024-07-11 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-07-1203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-04-11 | Fine | $13,065 | 0 |
| 2025-08-07 | Fine | $21,548 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- DOUGLAS G PENDERGRAS SR ESTATEOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST50% · since 03/20/2018
- PENAN RETIREMENT INC.Organization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2018
- PENDERGRAS, DONIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST50% · since 01/01/2018
- DOUGLAS G PENDERGRAS SR ESTATEOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 03/20/2018
- PENDERGRAS, DONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2018
- PENAN RETIREMENT INC.Organization · GENERAL PARTNERSHIP INTERESTNOT APPLICABLE · since 01/01/2018
- DOUGLAS G PENDERGRAS SR ESTATEOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2018
- ANNABI, MICHAELIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2018
- PERKINS, MICHAELIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2018
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.58per resident day
RN hours0.15per resident day
Weekend nurse hours3.16per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the El Paso ledger →Other published facilities nearby
Ambrosio Guillen Texas State Veterans Home160 beds · CMS overall 2/546 citation rowsAvir At El Paso124 beds · CMS overall 2/5115 citation rowsAvir At Patriot124 beds · CMS overall 1/589 citation rowsAvir At Tierra Este120 beds · CMS overall 1/576 citation rowsCenter At Zaragoza, Llc80 beds · CMS overall 4/546 citation rowsEdgemere Estates138 beds · CMS overall 1/582 citation rowsEl Paso Health & Rehabilitation Center150 beds · CMS overall 1/569 citation rowsFranklin Heights Nursing & Rehabilitation132 beds · CMS overall 1/591 citation rows