D63

THE BARTLETT SKILLED NURSING AND ASSISTED LIVING

Grade D 63/100 composite score

For profit - PartnershipAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
2/5
Quality
3/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

58

Ownership

For profit - Partnership

Total Fines

$33,150

Last Survey

N/A

221 BARTLETT DRIVE, EL PASO, TX 79912
9155848438

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Staffing

Staffing data not available for this facility.

Ownership

DOUGLAS G PENDERGRAS SR ESTATE

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Mar 2018

50%

PENAN RETIREMENT INC.

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 2018

PENDERGRAS, DON

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 2018

50%

PENAN RETIREMENT INC.

OrganizationGENERAL PARTNERSHIP INTERESTSince Jan 2018

PENDERGRAS, DON

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2018

DOUGLAS G PENDERGRAS SR ESTATE

Organization5% OR GREATER SECURITY INTERESTSince Mar 2018

Penalties & Fines (1)

$33,150total fines
DateTypeDescriptionAmount
Aug 7, 2025Fine$33,150

Health Inspection Deficiencies (33)

August 22, 2025Health5 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Aug 25, 2025
0656EMinimal harm, Pattern

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

Corrected Aug 25, 2025
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Aug 25, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 25, 2025
0945EMinimal harm, Pattern

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

Corrected Aug 25, 2025
August 7, 2025Health3 deficiencies1 severe
0600GActual harm, Isolated

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

Corrected Aug 27, 2025
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 27, 2025
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 27, 2025
March 13, 2025Health1 deficiency
0842DMinimal harm, Isolated

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

Corrected Mar 14, 2025
February 6, 2025Health2 deficiencies
0694EMinimal harm, Pattern

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Feb 7, 2025
0761DMinimal harm, Isolated

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

Corrected Feb 7, 2025
July 11, 2024Health8 deficiencies
0656DMinimal harm, Isolated

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

Corrected Jul 12, 2024
0698EMinimal harm, Pattern

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Jul 26, 2024
0756DMinimal harm, Isolated

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

Corrected Jul 26, 2024
0758EMinimal harm, Pattern

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

Corrected Jul 12, 2024
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jul 12, 2024
0842DMinimal harm, Isolated

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

Corrected Jul 26, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jul 12, 2024
0944FMinimal harm, Widespread

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies

Corrected Aug 1, 2024
June 15, 2023Health14 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Jul 3, 2023
0565DMinimal harm, Isolated

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Jul 3, 2023
0576DMinimal harm, Isolated

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies

Corrected Jul 3, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 3, 2023
0655DMinimal harm, Isolated

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

Corrected Jul 3, 2023
0656DMinimal harm, Isolated

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

Corrected Jul 3, 2023
0690DMinimal harm, Isolated

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

Corrected Jul 3, 2023
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Jul 3, 2023
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jul 3, 2023
0758EMinimal harm, Pattern

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

Corrected Jul 3, 2023
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jul 3, 2023
0814EMinimal harm, Pattern

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Jul 3, 2023
0842DMinimal harm, Isolated

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

Corrected Jul 3, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jul 3, 2023

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Frequently Asked Questions

What is the CareGrader rating for THE BARTLETT SKILLED NURSING AND ASSISTED LIVING?

THE BARTLETT SKILLED NURSING AND ASSISTED LIVING in EL PASO, Texas has a CareGrader grade of D (Below Average), with a composite score of 63 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for THE BARTLETT SKILLED NURSING AND ASSISTED LIVING?

THE BARTLETT SKILLED NURSING AND ASSISTED LIVING has an overall CMS star rating of 1 out of 5, a health inspection rating of 2/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does THE BARTLETT SKILLED NURSING AND ASSISTED LIVING have?

THE BARTLETT SKILLED NURSING AND ASSISTED LIVING has 33 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has THE BARTLETT SKILLED NURSING AND ASSISTED LIVING been fined?

Yes. THE BARTLETT SKILLED NURSING AND ASSISTED LIVING has $33,150 in total fines from CMS enforcement actions across 1 penalty.

How many beds does THE BARTLETT SKILLED NURSING AND ASSISTED LIVING have?

THE BARTLETT SKILLED NURSING AND ASSISTED LIVING has 58 certified beds with approximately 60 current residents (103% occupancy). The facility is located at 221 BARTLETT DRIVE, EL PASO, Texas 79912. It is a for profit - partnership facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.