Facility WatchInspection records for every certified US nursing home
THE Pavilion at Creekwood
2100 Cannon DR Mansfield, TX 76063 (817) 779-6500
CCN
676388
Certified beds
126
Ownership
For profit - Limited Liability company
Chain
Fundamental Healthcare
Nurse staffing
3.01
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.35 hours per resident per day
Nursing staff turnover: 47% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected August 6, 2025
2 citations · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 7, 2025
E
F0686No actual harm with potential for more than minimal harm · Pattern
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected August 7, 2025
Inspected February 26, 2025
4 citations · Health
D
F0585No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected February 27, 2025
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected February 27, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected February 27, 2025
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected February 27, 2025
Inspected January 5, 2025
3 citations · from a complaint investigation · Health
J
F0684Immediate jeopardy to resident health or safety · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected January 6, 2025
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 6, 2025
J
F0742Immediate jeopardy to resident health or safety · Isolated
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.
Deficient, Provider has date of correction · corrected January 6, 2025
Inspected August 27, 2024
1 citation · from a complaint investigation · Health
J
F0578Immediate jeopardy to resident health or safety · Isolated
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.
Deficient, Provider has date of correction · corrected August 28, 2024
Inspected May 20, 2024
2 citations · from a complaint investigation · Health
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected May 21, 2024
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected May 21, 2024
Inspected January 25, 2024
2 citations · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected January 27, 2024
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected January 27, 2024
Inspected December 12, 2023
1 citation · from a complaint investigation · Health
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected December 13, 2023
Inspected November 21, 2023
2 citations · from a complaint investigation · Health
D
F0919No actual harm with potential for more than minimal harm · Isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected November 22, 2023
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 18, 2023
Inspected November 30, 2022
4 citations · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected December 1, 2022
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected December 6, 2022
E
F0730No actual harm with potential for more than minimal harm · Pattern
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected December 19, 2022
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 28, 2022