Bear Creek Nursing and Rehabilitation
3729 Ira E Woods Avenue, Grapevine, TX 76051 · Tarrant County · 100 certified beds · avg 74 residents/day · certified since Jul 21, 2016
Part of chain: EDURO HEALTHCARE (34 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Dec 21, 2025 · F-0755 · triggered by a complaint
The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Why it matters: Weak pharmacy services lead to medication mistakes, delays, and missed drug interactions that can seriously harm residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 22, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Dec 21, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 22, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 25, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 25, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 25, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 30, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 20, 2023 (Past Non-Compliance)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 27, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 27, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 27, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Dec 21, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 21, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Nov 19, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Nov 19, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 20, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 20, 2025 | E · Potential for harm, repeated | The facility's bedrooms did not give residents visual privacy — such as curtains or dividers — when privacy is needed. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 4, 2025 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Feb 4, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Nov 27, 2024 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. · from a complaint |
| Oct 25, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Oct 25, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 25, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 25, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Feb 15, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 15, 2024 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Feb 15, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 15, 2024 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 15, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 15, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Jan 30, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 30, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 1 | J ▲ |
| 2024 | 14 | 3 | K ▲ |
| 2025 | 14 | 2 | K ▲ |
| 2026 | 8 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $122,257.
| Date | Type | Amount / length |
|---|---|---|
| Dec 21, 2025 | Fine | $48,945 |
| Oct 25, 2024 | Fine | $65,866 |
| Oct 30, 2023 | Fine | $7,446 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.44 | 3.46 | 3.95 | top 40% in Texas; bottom 33% in the U.S. |
| Registered Nurse hours | 0.69 | 0.44 | 0.69 | top 10% in Texas; top 37% in the U.S. |
| Weekend total nurse staffing | 3.11 | 3.04 | 3.50 | top 34% in Texas; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.47 | 0.34 | 0.48 | top 16% in Texas; top 37% in the U.S. |
| Total nursing staff turnover (%) | 55.0 | 55.3 | 45.8 | bottom 43% in Texas; bottom 25% in the U.S. |
| RN turnover (%) | 62.5 | 54.6 | 42.9 | bottom 38% in Texas; bottom 19% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.31, RN 0.67, weekend 2.99. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Maverick County Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/01/2022 |
| Bewsey, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2022 |
| Grapevine Nursing and Rehab Center, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2022 |
| Martinez, Alma | Individual | Corporate Director | NOT APPLICABLE | 06/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Grapevine Medical Lodge | 2.8 mi | Grapevine, TX | ★★★★★ | 4/5 | |
| Avir at Grapevine | 2.9 mi | Grapevine, TX | ★★☆☆☆ | 2/5 | |
| Keller Oaks Healthcare Center | 3.5 mi | Keller, TX | ★★★★☆ | 4/5 | |
| The Carlyle at Stonebridge Park | 3.9 mi | Southlake, TX | ★☆☆☆☆ | 2/5 | |
| Discovery Village at Southlake | 4.2 mi | Southlake, TX | ★★★★★ | 5/5 | |
| Oakmont Guest Care Center | 4.5 mi | Hurst, TX | ★☆☆☆☆ | 1/5 | |
| La Dora Nursing and Rehabilitation Center | 4.8 mi | Bedford, TX | ★★★★★ | 5/5 | |
| Forum Parkway Health & Rehabilitation | 5.1 mi | Bedford, TX | ★★★☆☆ | 3/5 | |
| Bedford Wellness & Rehabilitation | 5.3 mi | Bedford, TX | ★★★☆☆ | 3/5 | |
| Parkwood Village | 5.8 mi | Bedford, TX | ★★★★☆ | 4/5 | |
| Westpark Rehabilitation and Living | 6.2 mi | Euless, TX | ★☆☆☆☆ | 1/5 | |
| Hurst Plaza Nursing and Rehab | 6.5 mi | Hurst, TX | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676408.