Cycle 1
Health 2025-04-15 · Fire 2025-04-15
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Grapevine, TX
Grapevine Medical Lodge
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1005 Ira E. Woods Parkway, Grapevine, TX
(817) 421-1313
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
94
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
2006-06-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.13
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.77
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,883
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9913
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.56
Baseline 22.89% · Performance 20.51% · Measure score 3.56 · Achievement 1.98 · Improvement 3.56
Healthcare-associated infections
6.80
Baseline 9.32% · Performance 6.16% · Measure score 6.80 · Achievement 5.59 · Improvement 6.80
Total nurse turnover
4.94
Baseline 70.00% · Performance 45.45% · Measure score 4.94 · Achievement 4.46 · Improvement 4.94
Adjusted total nurse staffing
0
Baseline 3 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 252 · Observed rate 9.92% · Lower 95% interval 8.17% |
| Discharge to community | 51.64% |
50.57%
1.1 pts better
|
No Different than the National Rate · Eligible stays 218 · Observed rate 45.41% · Lower 95% interval 45.34% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.95% |
95.27%
3.7 pts better
|
Numerator 189 · Denominator 191 |
| Falls with major injury | 0.52% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 191 |
| Discharge self-care score | 56.92% |
53.69%
3.2 pts better
|
Numerator 74 · Denominator 130 |
| Discharge mobility score | 33.08% |
50.94%
17.9 pts worse
|
Numerator 43 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 2.09% |
2.29%
0.2 pts better
|
Numerator 4 · Denominator 191 · Adjusted rate 1.55% |
| Healthcare-associated infections requiring hospitalization | 6.16% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 168 · Observed rate 5.36% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 16.43% |
42%
25.6 pts worse
|
Numerator 23 · Denominator 140 |
| Discharge function score | 54.62% |
56.45%
1.8 pts worse
|
Numerator 71 · Denominator 130 |
| Transfer of health information to provider | 97.67% |
95.95%
1.7 pts better
|
Numerator 42 · Denominator 43 |
| Transfer of health information to patient | 96.33% |
96.28%
About the same
|
Numerator 105 · Denominator 109 |
| Resident COVID-19 vaccinations up to date | 7.37% |
25.2%
17.8 pts worse
|
Numerator 7 · Denominator 95 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.3%
0.7 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.3% · Q3 4.8% · Q4 4.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
2.7%
0.5 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 3.8% · Q4 1.7% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
18.9%
4 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 23.1% · Q3 22.6% · Q4 13.2% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
10.8%
5.5 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.8% · Q3 4.5% · Q4 2.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.0% |
15.4%
8.4 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 0.0% · Q4 8.7% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.5% |
16.1%
13.6 pts better
|
14.9%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 2.0% · Q4 3.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.9% |
15.0%
0.9 pts worse
|
19.8%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 20.7% · Q3 14.3% · Q4 7.0% · 4Q avg 15.9% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 1.6% · Q3 1.4% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
12.0%
2.5 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 8.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.9%
1.8 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 19.3% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-12-14 · Fire 2022-12-14
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-05-09
F · Potential for more than minimal harm
2024-03-07
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-03-07
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-19
F · Potential for more than minimal harm
2022-12-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-15
F693 · Quality of Life and Care Deficiencies
Health
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 2025-05-09
E · Potential for more than minimal harm
2025-04-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-15
F761 · Pharmacy Service Deficiencies
Health
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 2025-05-09
E · Potential for more than minimal harm
2025-04-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-15
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-09
E · Potential for more than minimal harm
2022-12-14
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-04
Penalties and ownership
What sits behind the stars
Ownership
Decatur Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Caretrust Reit Inc
5% Or Greater Mortgage Interest · Organization
Ctr Partnership LP
5% Or Greater Mortgage Interest · Organization
Pmg Opco-Grapevine LLC
Operational/Managerial Control · Organization
Scroggins, Brian
Corporate Officer · Individual
Taggart, Douglas
Operational/Managerial Control · Individual
Nearby options
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#2
Bear Creek Nursing And Rehabilitation
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2-star overall rating with 1-star inspections with $142,612 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
The Carlyle at Stonebridge Park
Southlake, TX
3-star overall rating with 2-star inspections with $125,895 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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