The Bartlett Skilled Nursing and Assisted Living
221 Bartlett Drive, El Paso, TX 79912
The Bartlett Skilled Nursing and Assisted Living is a nursing home in El Paso, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionAugust 22, 2025 (1 year ago)
- Health citations since June 15, 202337 (Texas average 28)
- Fines in the past three years2, $30,355 in total
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Fine
CMS changed the fine from April 11, 2026 from $13,065 to $8,492.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
Fine
CMS changed the fine from August 7, 2025 from $21,548 to $21,863.
CMS update of July 29, 2026
Health citation
CMS removed citation F0607 from the health inspection on April 11, 2026.
Fine
CMS changed the fine from August 7, 2025 from $33,150 to $21,548.
Health inspection on June 17, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 18, 2026.
CMS has cited this home for F0698 2 times since 2024.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on April 11, 2026
3 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
95 of 1,177 Texas homes (8%) got a citation at the actual harm level in 2026.
CMS fine of $8,492 on April 11, 2026.
Show the 3 citations
Citation F0627. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
CMS lists it as corrected on April 30, 2026.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 30, 2026.
CMS has cited this home for F0842 4 times since 2023.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 30, 2026.
CMS update of December 15, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on August 22, 2025
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on August 25, 2025.
CMS has cited this home for F0656 3 times since 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on August 25, 2025.
CMS has cited this home for F0812 3 times since 2023.
Citation F0945. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS lists it as corrected on August 25, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on August 25, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 25, 2025.
CMS has cited this home for F0880 3 times since 2023.
Fire safety inspection on August 22, 2025
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on October 28, 2025.
CMS has cited this home for E0039 2 times since 2024.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on October 28, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 28, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on October 28, 2025.
CMS has cited this home for K0918 2 times since 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on October 28, 2025.
CMS has cited this home for K0372 2 times since 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on October 28, 2025.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on October 28, 2025.
Health inspection on August 7, 2025
3 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
107 of 1,177 Texas homes (9%) got a citation at the actual harm level in 2025.
CMS fine of $21,863 on August 7, 2025.
Show the 3 citations
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 27, 2025.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on August 27, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 27, 2025.
CMS has cited this home for F0609 2 times since 2023.
CMS update of June 25, 2025
Health citation
CMS removed citation F0758 from the health inspection on July 11, 2024.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Health inspection on March 13, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on March 14, 2025.
Health inspection on February 6, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0694. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on February 7, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 7, 2025.
CMS update of December 20, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Health inspection on July 11, 2024
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation F0944. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on August 1, 2024.
Citation F0698. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on July 26, 2024.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 12, 2024.
CMS has cited this home for F0758 2 times since 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 12, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 12, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 12, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 26, 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 26, 2024.
Fire safety inspection on July 11, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on July 31, 2024.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 18, 2024.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of December 21, 2023
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Health inspection on June 15, 2023
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on July 3, 2023.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 3, 2023.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 3, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 3, 2023.
Citation F0814. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on July 3, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 3, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on July 3, 2023.
Citation F0565. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on July 3, 2023.
Citation F0576. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on July 3, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 3, 2023.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on July 3, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 3, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 3, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 3, 2023.
Fire safety inspection on June 15, 2023
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 28, 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on July 28, 2023.
Citation K0712. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 10, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (915) 584-8438
- Last standard health inspection
- August 22, 2025 (1 year ago)
- Certified beds
- 58
- Residents per day, on average
- 52.1
- Ownership type
- For profit - Partnership
- Legal business name
- Penan Retirement Centers Limited Partnership
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Texas average (37 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- DOUGLAS G PENDERGRAS SR ESTATE5% or greater direct ownership interest · 50% · since 03/20/2018
- PENAN RETIREMENT INC.5% or greater direct ownership interest · no percentage provided · since 01/01/2018
- PENDERGRAS, DON5% or greater direct ownership interest · 50% · since 01/01/2018
- PENDERGRAS, DONOperational/managerial control · not applicable · since 01/01/2018
Questions
When was The Bartlett Skilled Nursing and Assisted Living last inspected?
CMS lists August 22, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does The Bartlett Skilled Nursing and Assisted Living have?
CMS lists 37 health citations since June 15, 2023. CMS also calls these deficiencies.
Has The Bartlett Skilled Nursing and Assisted Living been fined?
CMS lists 2 fines in the past three years, $30,355 in total.
What is the CMS star rating of The Bartlett Skilled Nursing and Assisted Living?
Its CMS overall star rating is 2 of 5.
Is The Bartlett Skilled Nursing and Assisted Living a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.