Bear Creek Nursing and Rehabilitation
3729 Ira E Woods Avenue · Grapevine, TX · 76051 · 8175277500
100 certified beds For profit - Limited Liability company Chain: Eduro Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $141,166 in fines in the last 24 months.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$141,166 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.36 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.77 | 0.55–0.75 |
| Weekend hours / resident-day | 2.86 | ≈ weekday level |
| Nursing turnover / year | 57% | median 45% |
| Fines (3-yr window) | 3 · $148,612 |
Inspection citations (30 in the current record)
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Immediate jeopardy · K December 21, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 22, 2025 · Pharmacy Service
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Immediate jeopardy · K December 21, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected December 22, 2025 · Pharmacy Service
-
Potential for harm · D November 19, 2025 · found via complaint
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.
Corrected December 12, 2025 · Resident Rights
-
Potential for harm · D November 19, 2025 · found via complaint
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 December 12, 2025 · Pharmacy Service
-
Potential for harm · D March 20, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 20, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 11, 2025 · Quality of Life and Care
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Potential for harm · D March 20, 2025
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.
Corrected April 11, 2025 · Quality of Life and Care
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Potential for harm · D March 20, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 11, 2025 · Pharmacy Service
-
Potential for harm · D March 20, 2025
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 April 11, 2025 · Pharmacy Service
-
Potential for harm · D March 20, 2025
Provide and implement an infection prevention and control program.
Corrected April 11, 2025 · Infection Control
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Potential for harm · E March 20, 2025
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected April 11, 2025 · Environmental
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Potential for harm · E March 20, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected April 11, 2025 · Pharmacy Service
-
Potential for harm · D February 4, 2025 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected February 17, 2025 · Resident Rights
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Potential for harm · D February 4, 2025 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected February 17, 2025 · Quality of Life and Care
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Potential for harm · D November 27, 2024 · found via complaint
Give the resident's representative the ability to exercise the resident's rights.
Corrected December 19, 2024 · Resident Rights
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Immediate jeopardy · K October 25, 2024 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected November 20, 2024 · Resident Rights
-
Immediate jeopardy · K October 25, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected November 20, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K October 25, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 20, 2024 · Quality of Life and Care
-
Potential for harm · E October 25, 2024 · found via complaint
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.
Corrected November 20, 2024 · Resident Rights
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Potential for harm · E February 15, 2024
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.
Corrected March 31, 2024 · Resident Rights
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Potential for harm · D February 15, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 31, 2024 · Resident Assessment and Care Planning
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Potential for harm · E February 15, 2024
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.
Corrected March 31, 2024 · Nursing and Physician Services
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Potential for harm · E February 15, 2024
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 March 31, 2024 · Pharmacy Service
-
Potential for harm · E February 15, 2024
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.
Corrected March 31, 2024 · Nutrition and Dietary
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Potential for harm · E February 15, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected March 31, 2024 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 21, 2025 | Fine | $75,300 |
| October 25, 2024 | Fine | $65,866 |
| October 30, 2023 | Fine | $7,446 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676408 · certified since July 21, 2016. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.