El Paso, TX
1-star overall rating with 2-star inspections with abuse icon flag with $33,150 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
221 Bartlett Drive, El Paso, TX
(915) 584-8438
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
58
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-11-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.4% |
18.9%
16.5 pts better
|
19.6%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 39.4% |
10.8%
28.6 pts worse
|
16.7%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
16.1%
1.8 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.5%
2.9 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
15.0%
13.6 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 16.3% |
4.2%
12.1 pts worse
|
5.1%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
12.0%
2.8 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
88.0%
11 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
25.9%
4.6 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-28
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-10-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-28
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-10
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-25
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-08-25
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-25
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-27
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-27
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-14
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-02-07
Health
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.
Corrected 2025-02-07
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-08-01
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-26
Health
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.
Corrected 2024-07-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-12
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-12
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-07-26
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-03
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-03
Health
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.
Corrected 2023-07-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-03
Health
Dispose of garbage and refuse properly.
Corrected 2023-07-03
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-03
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-03
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-07-03
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-07-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-03
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-03
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-03
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-03
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-03
Penalties and ownership
Fine · fine $33,150
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Security Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
General Partnership Interest · Organization
Operational/Managerial Control · Individual
Nearby options
El Paso, TX
2-star overall rating with 3-star inspections with $4,475 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
El Paso, TX
2-star overall rating with 1-star inspections with $191,503 in total fines with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
El Paso, TX
1-star overall rating with 1-star inspections with $199,581 in total fines with 15 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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