Report
TheVardellReport
Bear Creek Nursing and Rehabilitation
Skilled nursing facility and nursing facility
3729 Ira E Woods Avenue
Grapevine, TX 76051
Report
← Bear Creek Nursing and Rehabilitation, free profile
Life by Vardell Presents
The Vardell Report.Bear Creek Nursing and Rehabilitation
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Grapevine, TX
- Record Period
- 2023–2026
- Source Documents
- 16
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 14 inspections from October 2023 to July 2026, state surveyors documented 40 findings at Bear Creek Nursing and Rehabilitation; 37 have a recorded correction and 3 await one; CMS lists 3 enforcement actions in the window.
- Inspections
- 14
- 2023–2026, complaint, standard and infection control
- Findings
- 40
- Deficiencies cited by state inspectors
- Corrected
- 37
- Of 40 findings, with a recorded correction date
- Penalties
- 3
- 3 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 3 | 1 | 1 |
| 2024 | 4 | 14 | 3 |
| 2025 | 4 | 14 | 2 |
| 2026 | 3 | 11 | 0 |
What the Record Shows
- 37 of 40 findings have a recorded correction date.
- CMS lists 3 enforcement actions in the window: 3 fines totaling $122,989, their payment not published.
- 10 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, May 7, 2026, recorded 5 findings (most serious: Level D).
What to Ask About
- Pharmacy Services, Cited in Three Inspections
- Medication Labeling and Storage, Cited in Three Inspections
- Grievances, Cited in Two Inspections
- Dialysis Care, Cited in Two Inspections
- Medical Records, Cited in Two Inspections
- Accident Hazards and Supervision, No Recorded Correction
- Significant Medication Errors, No Recorded Correction
- Infection Control, No Recorded Correction
Report at a Glance
- Facility
- Bear Creek Nursing and Rehabilitation
- Address
- 3729 Ira E Woods Avenue, Grapevine, TX 76051
- CMS Certification Number
- 676408
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 100
- Ownership
- For profit - Limited Liability company
- Record Window
- October 3, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
3 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
3 findings
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 12, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 12, 2026
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jul 12, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Standard health inspection
5 findings
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected May 15, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level KImmediate jeopardyCorrected Dec 22, 2025
- F760Ensure that residents are free from significant medication errors.Level KImmediate jeopardyCorrected Dec 22, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
8 findings
The same visit included a complaint investigation.
- F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F914Provide bedrooms that don't allow residents to see each other when privacy is needed.Level ENo actual harm, potential for moreCorrected Apr 11, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 11, 2025
Enforcement Action
Civil money penalty, $49,677 imposed December 21, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 20, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Feb 17, 2025
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 17, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F551Give the resident's representative the ability to exercise the resident's rights.Level DNo actual harm, potential for moreCorrected Dec 19, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
4 findings
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level KImmediate jeopardyCorrected Nov 20, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level KImmediate jeopardyCorrected Nov 20, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level KImmediate jeopardyCorrected Nov 20, 2024
- F585Honor 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.Level ENo actual harm, potential for moreCorrected Nov 20, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
8 findings
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Mar 31, 2024
- F727Have 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.Level ENo actual harm, potential for moreCorrected Mar 31, 2024
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Mar 31, 2024
- F803Ensure 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.Level ENo actual harm, potential for moreCorrected Mar 31, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Mar 31, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Mar 31, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 31, 2024
- F809Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 31, 2024
Enforcement Action
Civil money penalty, $65,866 imposed October 25, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 15, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
The same visit included an infection control inspection.
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Infection control inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Oct 20, 2023
Enforcement Action
Civil money penalty, $7,446 imposed October 30, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of October 30, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Infection control inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Pharmacy Services, Cited in Three Inspections
Inspectors cited F755 in March 2025, December 2025 and May 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323232424242425252525262626F755 across all 14 inspections, oldest to newest - 2
Medication Labeling and Storage, Cited in Three Inspections
Inspectors cited F761 in February 2024, March 2025 and November 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323232424242425252525262626F761 across all 14 inspections, oldest to newest - 3
Grievances, Cited in Two Inspections
Inspectors cited F585 in October 2024 and November 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323232424242425252525262626F585 across all 14 inspections, oldest to newest - 4
Dialysis Care, Cited in Two Inspections
Inspectors cited F698 in February 2025 and May 2026. This citation covers care for residents who need dialysis. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323232424242425252525262626F698 across all 14 inspections, oldest to newest - 5
Medical Records, Cited in Two Inspections
Inspectors cited F842 in February 2024 and May 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323232424242425252525262626F842 across all 14 inspections, oldest to newest - 6
Accident Hazards and Supervision, No Recorded Correction
F689 was cited in October 2023, March 2025, June 2026 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level J (immediate jeopardy). The July 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
2323232424242425252525262626F689 across all 14 inspections, oldest to newest - 7
Significant Medication Errors, No Recorded Correction
F760 was cited in March 2025, December 2025 and July 2026. This citation covers whether residents are free from significant medication errors. The most serious was level K (immediate jeopardy). The July 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
2323232424242425252525262626F760 across all 14 inspections, oldest to newest - 8
Infection Control, No Recorded Correction
F880 was cited in January 2024, March 2025, June 2026 and July 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious was level E (no actual harm, potential for more). The July 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
2323232424242425252525262626F880 across all 14 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in three inspections, most seriously at level K.
- 02
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level E.
- 03
How do we file a grievance, who answers it, and how quickly?
Grievances: cited in two inspections, most seriously at level E.
- 04
How is dialysis care coordinated, and who monitors residents before and after treatment?
Dialysis Care: cited in two inspections, most seriously at level D.
- 05
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level E.
- 06
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level J. The July 28, 2026 citation has no recorded correction date.
- 07
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in three inspections, most seriously at level K. The July 28, 2026 citation has no recorded correction date.
- 08
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level E. The July 28, 2026 citation has no recorded correction date.
- 09
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 10
What led to the 2025 fine, and has it been paid?
A $49,677 civil money penalty was imposed December 21, 2025. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Oct 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Oct 30, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Dec 4, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jan 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Feb 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Oct 25, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Nov 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Feb 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Mar 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Nov 19, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Dec 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection May 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jun 27, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jul 28, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 676408
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowOctober 3, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before October 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.