THE PAVILION AT CREEKWOOD
2100 CANNON DR, MANSFIELD, TX 76063 · CCN 676388
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★☆ 4
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 126
- Avg residents/day
- 99.8
- Phone
- 8177796500
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-02-26 | 6 | 9.1 | 9.5 | -3.1 better |
| 2 | 2024-01-25 | 8 | 9.4 | 9.8 | -1.4 better |
| 3 | 2022-11-30 | 8 | 8.1 | 9.3 | -0.1 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident assessment and care planning | 1 |
| Resident rights | 1 |
| Pharmacy service | 2 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.18 | 51.8% |
| RN staffing (reported) | 0.42 | 63.6% |
| Total nurse staffing (adjusted) | 3.09 | — |
Fines & penalties
- Total fines
- $39,674
- Number of fines
- 3
- Number of penalties
- 3
- Payment denials
- 0
Chain
- Chain
- FUNDAMENTAL HEALTHCARE
- Facilities in chain
- 69
- Chain avg overall
- 2.40 / 5
Inspection citations (22)4 immediate jeopardy
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-08-06 · Health · corrected 2025-08-07
Potential for more than minimal harm
- EF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-08-06 · Health · corrected 2025-08-07
Potential for more than minimal harm
- DF0585Honor 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.2025-02-26 · Health · corrected 2025-02-27
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-02-26 · Health · corrected 2025-02-27
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-02-26 · Health · corrected 2025-02-27
Potential for more than minimal harm
- EF0759Ensure medication error rates are not 5 percent or greater.2025-02-26 · Health · corrected 2025-02-27
Potential for more than minimal harm
- JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-01-05 · Health · corrected 2025-01-06
Immediate jeopardy
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-01-05 · Health · corrected 2025-01-06
Immediate jeopardy
- JF0742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.2025-01-05 · Health · corrected 2025-01-06
Immediate jeopardy
- JF0578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.2024-08-27 · Health · corrected 2024-08-28
Immediate jeopardy
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-05-20 · Health · corrected 2024-05-21
Potential for more than minimal harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-05-20 · Health · corrected 2024-05-21
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2024-01-25 · Health · corrected 2024-01-27
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-01-25 · Health · corrected 2024-01-27
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-12-12 · Health · corrected 2023-12-13
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2023-11-21 · Health · corrected 2023-12-18
Potential for more than minimal harm
- DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2023-11-21 · Health · corrected 2023-11-22
Potential for more than minimal harm
- DF0761Ensure 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.2023-03-21 · Health · corrected 2023-03-22
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2022-11-30 · Health · corrected 2022-12-01
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2022-11-30 · Health · corrected 2022-12-06
Potential for more than minimal harm
- EF0730Observe each nurse aide's job performance and give regular training.2022-11-30 · Health · corrected 2022-12-19
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2022-11-30 · Health · corrected 2022-12-28
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| THI OF TEXAS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2007-06-21 |
| HUNT VALLEY HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2010-02-09 |
| THI OF BALTIMORE, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2007-07-01 |
| FORMAN, MURRAY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2006-03-28 |
| THI OF TEXAS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2007-06-21 |
| LEBLANC, RYAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-01-01 |
| LEBLANC, RYAN | Individual | CORPORATE OFFICER | — | 2022-01-01 |
Other facilities in MANSFIELD
| Name | Overall | Beds |
|---|---|---|
| MANSFIELD MEDICAL LODGE | ★★★★☆ | 118 |
| MANSFIELD NURSING & REHABILITATION CENTER | ★★☆☆☆ | 127 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.