For profit - Limited Liability company · 126 certified beds · CMS number 676388
The Pavilion at Creekwood, Mansfield, TX
CMS records 25 health deficiencies at The Pavilion at Creekwood in Mansfield, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Apr 14, 2026. The highest severity cited is J (immediate jeopardy to resident health or safety). 4 citations were at the immediate jeopardy level. CMS lists 3 fines totaling $39,674 in the last three years.
- 25deficiencies, 3 cycles (TX median 25)
- 8in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $39,674fines, last 3 years
- 2CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for The Pavilion at Creekwood as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and The Pavilion at Creekwood may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (8 deficiencies)
Standard inspection Apr 14, 2026. CMS counts 8 health deficiencies and 6 fire safety deficiencies in this cycle.
Jun 1, 2026 · Complaint inspection
1 deficiency, highest D
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 2, 2026
Apr 14, 2026 · Standard inspection
7 deficiencies, highest E
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 15, 2026
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 15, 2026
F760 · No significant medication errors
Requirement cited (CMS): Ensure that residents are free from significant medication errors.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 15, 2026
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 15, 2026
F636 · Full assessment at admission and yearly
Requirement cited (CMS): Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 15, 2026
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 8, 2026
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 15, 2026
Previous cycle: 9 deficiencies (standard inspection Feb 26, 2025)
Standard inspection Feb 26, 2025. CMS counts 9 health deficiencies and 3 fire safety deficiencies in this cycle.
Aug 6, 2025 · Complaint inspection
2 deficiencies, highest E
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Aug 7, 2025
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 7, 2025
Feb 26, 2025 · Standard inspection
4 deficiencies, highest E
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 27, 2025
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 27, 2025
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 27, 2025
F585 · Grievances and how they are handled
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 27, 2025
Jan 5, 2025 · Complaint inspection
3 deficiencies, highest J
F742 · Treatment for mental health and trauma
Requirement cited (CMS): Provide 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.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jan 6, 2025
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jan 6, 2025
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jan 6, 2025
Earlier cycle: 8 deficiencies (standard inspection Jan 25, 2024)
Standard inspection Jan 25, 2024. CMS counts 8 health deficiencies and 2 fire safety deficiencies in this cycle.
Aug 27, 2024 · Complaint inspection
1 deficiency, highest J
F578 · Refusing treatment and advance directives
Requirement cited (CMS): Honor 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.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Aug 28, 2024
May 20, 2024 · Complaint inspection
2 deficiencies, highest E
F757 · Avoiding unnecessary drugs
Requirement cited (CMS): Ensure each resident’s drug regimen must be free from unnecessary drugs.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 21, 2024
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 21, 2024
Jan 25, 2024 · Standard inspection
2 deficiencies, highest F
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Jan 27, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 27, 2024
Dec 12, 2023 · Complaint inspection
1 deficiency, highest D
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 13, 2023
Nov 21, 2023 · Complaint inspection
2 deficiencies, highest E
F919 · Working call system
Requirement cited (CMS): Make sure that a working call system is available in each resident's bathroom and bathing area.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 22, 2023
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 18, 2023
- Found in
- infection control inspection
Tags cited in more than one inspection
5 tags cited on more than one inspection date at The Pavilion at Creekwood; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F755 Pharmacy services and a consultant pharmacist | 3 | Apr 14, 2026; Feb 26, 2025; May 20, 2024 |
| F558 Accommodating individual needs and preferences | 2 | Apr 14, 2026; Jan 25, 2024 |
| F684 Quality of care | 2 | Aug 6, 2025; Jan 5, 2025 |
| F689 Accident prevention and supervision | 2 | Jun 1, 2026; Jan 5, 2025 |
| F812 Food safety and sanitation | 2 | Apr 14, 2026; Jan 25, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Jan 5, 2025 | Fine | $14,901 |
| Jan 5, 2025 | Fine | $14,901 |
| Aug 27, 2024 | Fine | $9,872 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.21 h (about the same as the Texas median of 3.27 h)
- RN hours per resident per day
- 0.38 h (about the same as the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.81 h
- Nursing staff turnover
- 47.0% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 2 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- 4 of 5
CMS figures for The Pavilion at Creekwood, copied as published; Texas medians are ours.
Facility details
- Address
- 2100 Cannon Dr, Mansfield, TX 76063
- Phone
- (817) 779-6500
- County
- Tarrant
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- Fundamental Healthcare
- Certified beds
- 126
- Average residents per day
- 97.3
- In Medicare/Medicaid since
- Aug 3, 2015
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are new medication orders filled, and how quickly can urgent medications arrive? (F755, cited 3 times)
- How does the home adapt rooms and routines for residents with limited mobility, vision, or hearing? (F558, cited 2 times)
- How does the home make sure doctor's orders are followed consistently across shifts? (F684, cited 2 times)
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 2 times)
Other nursing homes in Mansfield and the same chain
- Avir at Mansfield
Mansfield · 31 deficiencies - Mansfield Medical Lodge
Mansfield · 12 deficiencies - Corinth Rehabilitation Suites on the Parkway
Corinth · 48 deficiencies - Las Ventanas De Socorro
Socorro · 47 deficiencies - Terra Bella Health and Wellness Suites
Houston · 44 deficiencies - Avir at Memorial
Denison · 37 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.