The Bartlett Skilled Nursing And Assisted Living
El Paso, El Paso County, Texas · CCN 676457 · For-profit (Partnership) · not part of a chain
CMS rates The Bartlett Skilled Nursing And Assisted Living 1 of 5 overall as of August 2026. 58 certified beds, 54 residents a day on average. 37 citations on record from the current inspection cycles, 2 involving actual harm; 2 fines totalling $34,613.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 3 / 2 of 5 |
Staffing
| Total nurse staffing | 3.57563 hours per resident per day |
|---|---|
| Registered nurses | 0.1507 hours per resident per day |
| Weekend total | 3.16059 hours per resident per day |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-17 complaint survey |
Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-18 |
| 2026-04-11 complaint survey |
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Resident Rights Deficiencies · tag F0627 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-04-30 |
| 2026-04-11 complaint survey |
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 · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-30 |
| 2026-04-11 complaint survey |
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 · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Infection Control Deficiencies · tag F0945 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-25 |
| 2025-08-22 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-25 |
| 2025-08-07 complaint survey |
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 · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-08-27 |
| 2025-08-07 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-27 |
| 2025-08-07 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-27 |
| 2025-03-13 complaint survey |
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 · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-14 |
| 2025-02-06 complaint survey |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · tag F0694 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-02-07 |
| 2025-02-06 complaint survey |
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 · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-07 |
| 2024-07-11 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-01 |
| 2024-07-11 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0758 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-12 |
| 2024-07-11 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-26 |
| 2023-06-15 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0758 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-07-03 |
| 2023-06-15 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · tag F0814 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-07-03 |
| 2023-06-15 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-07-03 |
| 2023-06-15 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-03 |
| 2023-06-15 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · tag F0565 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-03 |
| 2023-06-15 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · tag F0576 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-03 |
| 2023-06-15 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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 Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-07-03 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-04-11 | Fine | $13,065 |
| 2025-08-07 | Fine | $21,548 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Douglas G Pendergras Sr Estate Organization | 5% or greater direct ownership interest | 50% | 2018-03-20 |
| Penan Retirement Inc. Organization | 5% or greater direct ownership interest | — | 2018-01-01 |
| Douglas G Pendergras Sr Estate Organization | 5% or greater security interest | — | 2018-03-20 |
| Douglas G Pendergras Sr Estate Organization | adp of the snf | — | 2018-01-01 |
| Penan Retirement Inc. Organization | general partnership interest | — | 2018-01-01 |
| Pendergras, Don Individual | 5% or greater direct ownership interest | 50% | 2018-01-01 |
| Annabi, Michael Individual | adp of the snf | — | 2018-01-01 |
| Perkins, Michael Individual | adp of the snf | — | 2018-01-01 |
| Pendergras, Don Individual | operational/managerial control | — | 2018-01-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for The Bartlett Skilled Nursing And Assisted Living.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in El Paso County.