Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grapevine Medical Lodge during CMS and state inspections, most recent first.
A resident with a history of dysphagia and multiple complex conditions was self-administering g-tube bolus feedings without a documented assessment or care plan for this practice. Although the resident was cognitively intact and had been trained previously, staff did not formally assess or document her ability to self-administer, and responsibilities for supervision and monitoring were unclear. This deficiency resulted in the resident performing all feedings herself without adequate support or care planning.
Two residents did not receive their scheduled morning medications within the required time frame due to a medication aide's delay after participating in a med pass observation. One resident missed timely pain management with Gabapentin, while another did not receive Creon with his meal as ordered for exocrine pancreatic insufficiency. Both residents' MARs reflected the late administration, and interviews confirmed the delay.
A medication cart containing insulin, prescription, and OTC medications was found unlocked and unattended near the main nursing station, with multiple people passing by. An LVN confirmed the cart should have been locked when not in use, and staff interviews indicated all medications must be secured according to facility policy.
Surveyors found that food items in the facility's kitchen refrigerator were not properly covered, labeled, or stored according to professional standards. Uncovered and unlabeled breadcrumbs and improperly covered pies were observed, with staff confirming these practices did not meet facility policy or food safety codes.
A resident with multiple complex medical conditions was self-administering her g-tube feedings three times daily, but the facility failed to assess or care plan for this practice. Although the resident was trained and sometimes supervised by nursing staff, her care plan did not include measurable objectives, timeframes, or interventions related to self-administration of enteral feedings, resulting in a lack of person-centered care planning.
A resident receiving IV antibiotics through a PICC line was administered medication while the PICC line dressing was loose, unsealed, and not intact. The nurse observed the compromised dressing but proceeded with the IV medication before changing the dressing, contrary to professional standards and physician orders. Facility policy and staff interviews confirmed that dressings should be changed if not intact, but this was not done prior to medication administration.
Failure to Assess and Care Plan for Self-Administration of Enteral Feeding
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident receiving enteral feeding was properly assessed and care planned for self-administration of gastrostomy tube (g-tube) bolus feedings. The resident, who was cognitively intact and her own responsible party, had a complex medical history including progressive systemic sclerosis, dysphagia, severe protein calorie malnutrition, and gastroparesis. Despite her ability to communicate and understand care instructions, there was no documented assessment or care plan addressing her self-administration of g-tube feedings upon both her initial and subsequent admissions. Observations and interviews revealed that the resident had been self-administering her g-tube feedings three times daily since admission, with minimal supervision from nursing staff. The resident reported being trained by previous nurses and expressed comfort with the procedure, but also stated she was fatigued from performing all feedings herself and had requested more assistance from staff. Nursing staff confirmed that while they had supervised her feedings in the past, there was no formal assessment or care plan in place for her self-administration, and responsibilities for monitoring and documentation were unclear among staff members. The facility's policy required periodic reassessment and documentation of the appropriateness and necessity of enteral nutrition, including input from the resident. However, the care plan and physician orders did not reflect the resident's self-administration of feeds, nor was there evidence of an initial or ongoing assessment for this practice. This lack of assessment and care planning could result in the resident's needs not being met and a decline in her health, as noted in the findings.
Delayed Medication Administration for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the timely and accurate administration of medications for two residents. Specifically, a medication aide (MA) administered Gabapentin, ordered for pain management, to one resident and Creon, ordered for exocrine pancreatic insufficiency, to another resident more than one hour after the scheduled administration time. Both residents were scheduled to receive their 8:00 am medications, but did not receive them until after 9:30 am. The medication administration records (MAR) for both residents were not initialed as given at the scheduled time, and interviews confirmed the delay. One resident, a cognitively intact male with diagnoses including muscle disorders, cellulitis, chronic foot ulcer, and neuropathy, reported not receiving his pain medication on time and expressed discomfort and pain during the interview. His care plan required medication to be administered as ordered for pain management. The other resident, also cognitively intact and diagnosed with bullous pemphigoid, exocrine pancreatic insufficiency, and other pancreatic diseases, did not receive his Creon medication with his meal as ordered, which was confirmed by both the resident and the MAR review. His care plan specified that medications should be administered with meals. The MA responsible for administering these medications was delayed in starting the medication pass due to participation in a medication pass observation with a nurse surveyor earlier that morning. This delay resulted in the late administration of scheduled medications for both residents. Facility policy required medications to be administered within one hour of the prescribed time unless otherwise specified, which was not followed in these instances.
Unattended and Unlocked Medication Cart Found in Facility
Penalty
Summary
Med Cart A was observed to be unlocked and unattended on two separate occasions near the main nursing station, with the lock mechanism visibly disengaged. During these times, residents, family members, staff, and surveyors were able to walk by the cart, which contained insulin, over-the-counter, and prescription medications. No staff member was present or using the cart at the time of the observations. When approached, an LVN stated she did not know who was responsible for the cart, but acknowledged that it should have been locked when not in use and proceeded to secure it. Interviews with staff confirmed that the expectation was for all medications, including those at the bedside, to be secured and reported if found otherwise. The DON and Administrator both stated that the facility's policy required medication carts to be locked when not in direct use, and that all nursing staff were responsible for ensuring this. Review of facility policy and staff training materials further supported the requirement that medication carts not be left unlocked and unattended.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Specifically, a plastic container with breadcrumbs was found uncovered and unlabeled on the bottom shelf of the refrigerator. Additionally, a package of blueberries was observed sitting on top of premade pies, with only parchment paper separating the items, and the parchment paper was in direct contact with the pie crust. Staff interviews confirmed that food items should be covered, labeled, and dated, and that each pie should have been individually wrapped to prevent contamination. The facility's Food Storage policy requires all refrigerated foods to be dated, labeled, and tightly sealed in approved containers, and the U.S. Public Health Service Food Code mandates protection of food from contamination and proper date marking. The Dietary Manager acknowledged that the observed practices did not meet these standards and identified the risk of contamination. The DON and Administrator both stated that staff are expected to follow food storage and handling procedures, but could not specify the risks associated with non-compliance. No specific residents were identified as being directly affected at the time of the deficiency.
Failure to Care Plan for Self-Administration of G-Tube Feedings
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all of a resident's needs, specifically omitting the assessment and care planning for self-administration of gastrostomy tube (g-tube) feedings. The resident, a cognitively intact female with multiple complex diagnoses including progressive systemic sclerosis, dysphagia, and severe malnutrition, had been self-administering her g-tube bolus feedings three times daily since admission. Despite this, her care plan did not reflect an assessment or interventions for self-administration of enteral feedings, nor did it include measurable objectives or timeframes related to this aspect of her care. Observations and interviews revealed that the resident was comfortable performing her own g-tube feedings but expressed fatigue and a desire for more assistance from staff. Nursing staff confirmed that the resident had been trained to self-administer her feedings and that supervision was provided inconsistently. However, there was no documented assessment of her ability to self-administer, and the care plan did not address this practice. Staff interviews indicated a lack of clarity regarding responsibility for care planning and assessment of self-administration, with some staff believing the resident was care planned for this and others stating it was not within their scope to complete such care plans. The facility's policy required the interdisciplinary team to develop and update comprehensive, person-centered care plans in response to changes in a resident's condition or care needs. Despite this, the care plan for this resident did not reflect her actual practice of self-administering g-tube feedings, nor did it include the necessary assessments or interventions to ensure her needs were met. This omission was identified through record review, staff and resident interviews, and observation, demonstrating a failure to provide a complete and individualized care plan as required.
Failure to Maintain Intact PICC Line Dressing During IV Medication Administration
Penalty
Summary
A deficiency occurred when a resident receiving intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC) line was observed with a loose, unsealed, and non-intact PICC line dressing. The dressing was visibly lifted on one side, with the bio patch exposed to air, and the paper tape previously used for reinforcement was hanging off and not sealing the dressing. The dressing was dated from a previous week and had not been changed despite its compromised condition. The resident was non-interviewable, and her family was unsure if the dressing had been changed since admission. The nurse responsible for administering the resident's antibiotics acknowledged noticing the loose and unsealed dressing prior to starting the IV medication but chose to complete the antibiotic infusions before planning to change the dressing. The nurse was not immediately aware of the specific schedule for dressing changes without consulting the resident's orders and stated that dressing changes were typically performed every seven days or as needed. The nurse confirmed that the dressing was not changed or reinforced before administering the IV medication, despite recognizing the importance of maintaining an intact dressing for infection control. Interviews with other nursing staff and facility leadership confirmed that the expectation was for PICC line dressings to be changed if they became loose, soiled, or non-intact, in addition to the routine schedule. Facility policy also required dressing changes under these circumstances. Documentation showed that the dressing was eventually changed later that day, but at the time of the deficiency, the resident received IV medication through a compromised PICC line dressing, contrary to professional standards of practice and physician orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grapevine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Grapevine | 1 mi | ★★★★★ | 11 | 0 |
| Bear Creek Nursing And Rehabilitation | 2.8 mi | ★★★★★ | 14 | 2 |
| The Carlyle At Stonebridge Park | 6 mi | ★★★★★ | 14 | 1 |
| Keller Oaks Healthcare Center | 6.2 mi | ★★★★★ | 2 | 0 |
| Discovery Village At Southlake | 6.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.