D-
41/100BEAR CREEK NURSING AND REHABILITATION Inspection Report, Violations & Safety Grade (GRAPEVINE, Texas)
3729 IRA E WOODS AVENUE, GRAPEVINE, Texas 76051
Phone: 8175277500
CMS Overall:1/5
Overview & Bed Count
Certified Beds
100
Avg Residents/Day
68.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Tarrant
Sprinkler Systems
Yes
Special Focus
SFF Candidate
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing2/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.65 | 0.44 | +0.21 |
| Total Nurse Hours per Resident per Day | 3.47 | 3.42 | +0.05 |
| CMS Staffing Rating | 2/5 | 1.9/5 | - |
| Nursing Staff Turnover | 59.0% | 50.8% | - |
Health Citation History
40 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-28 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2026-07-28 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2026-07-28 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-06-27 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2026-06-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2026-06-27 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-05-07 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2026-05-07 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-05-07 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2026-05-07 | 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. | D – Moderate Harm Potential |
| 2026-05-07 | Administration Deficiencies | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | D – Moderate Harm Potential |
| 2025-12-21 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | K – Immediate Jeopardy |
| 2025-12-21 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | K – Immediate Jeopardy |
| 2025-11-19 | 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. | D – Moderate Harm Potential |
| 2025-11-19 | 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. | D – Moderate Harm Potential |
| 2025-03-20 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | E – Moderate Harm Potential |
| 2025-03-20 | Environmental Deficiencies | Provide bedrooms that don't allow residents to see each other when privacy is needed. | E – Moderate Harm Potential |
| 2025-03-20 | 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. | D – Moderate Harm Potential |
| 2025-03-20 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-03-20 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2025-03-20 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-03-20 | 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. | D – Moderate Harm Potential |
| 2025-03-20 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-02-04 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2025-02-04 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-11-27 | Resident Rights Deficiencies | Give the resident's representative the ability to exercise the resident's rights. | D – Moderate Harm Potential |
| 2024-10-25 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | K – Immediate Jeopardy |
| 2024-10-25 | 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. | K – Immediate Jeopardy |
| 2024-10-25 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2024-10-25 | 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. | E – Moderate Harm Potential |
| 2024-02-15 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E – Moderate Harm Potential |
| 2024-02-15 | Nursing and Physician Services Deficiencies | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | E – Moderate Harm Potential |
| 2024-02-15 | 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. | E – Moderate Harm Potential |
| 2024-02-15 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | E – Moderate Harm Potential |
| 2024-02-15 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2024-02-15 | 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. | E – Moderate Harm Potential |
| 2024-02-15 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-02-15 | Nutrition and Dietary Deficiencies | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | D – Moderate Harm Potential |
| 2024-01-30 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2023-10-30 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
Fire Safety Citation History
14 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-05-07 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2026-05-07 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2026-05-07 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2026-05-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2026-05-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure electrical receptacles or cover plates have distinctive color or marking. | D – Moderate Harm Potential |
| 2025-03-20 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | C – Minimal Harm Potential |
| 2024-02-15 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-02-15 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | F – Moderate Harm Potential |
| 2024-02-15 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-02-15 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | F – Moderate Harm Potential |
| 2024-02-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-02-15 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2024-02-15 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-02-15 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
Total Penalties & Fines
$122,989
Total Fine Amount (CMS)
3
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-12-21 | Fine | $49,677 | - |
| 2024-10-25 | Fine | $65,866 | - |
| 2023-10-30 | Fine | $7,446 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the GRAPEVINE area at no cost.
Find Safe, Vetted Facilities Near GRAPEVINE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.