The Pavilion at Creekwood
2100 Cannon Dr · Mansfield, TX · 76063 · 8177796500
126 certified beds For profit - Limited Liability company Chain: Fundamental Healthcare
Why this verdict
- Federal penalties on record: $39,674 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
Red flags
4 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.13 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.37 | 0.55–0.75 |
| Weekend hours / resident-day | 2.84 | ≈ weekday level |
| Nursing turnover / year | 47% | median 45% |
| Fines (3-yr window) | 3 · $39,674 |
Inspection citations (21 in the current record)
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Potential for harm · D August 6, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 7, 2025 · Quality of Life and Care
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Potential for harm · E August 6, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected August 7, 2025 · Quality of Life and Care
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Potential for harm · D February 26, 2025
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.
Corrected February 27, 2025 · Resident Rights
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Potential for harm · D February 26, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected February 27, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 26, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 27, 2025 · Pharmacy Service
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Potential for harm · E February 26, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected February 27, 2025 · Pharmacy Service
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Immediate jeopardy · J January 5, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 6, 2025 · Quality of Life and Care
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Immediate jeopardy · J January 5, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 6, 2025 · Quality of Life and Care
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Immediate jeopardy · J January 5, 2025 · found via complaint
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.
Corrected January 6, 2025 · Quality of Life and Care
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Immediate jeopardy · J August 27, 2024 · found via complaint
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.
Corrected August 28, 2024 · Resident Rights
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Potential for harm · E May 20, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 21, 2024 · Pharmacy Service
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Potential for harm · D May 20, 2024 · found via complaint
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 21, 2024 · Pharmacy Service
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Potential for harm · D January 25, 2024
Reasonably accommodate the needs and preferences of each resident.
Corrected January 27, 2024 · Resident Rights
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Potential for harm · F January 25, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 27, 2024 · Nutrition and Dietary
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Potential for harm · D December 12, 2023 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 13, 2023 · Quality of Life and Care
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Potential for harm · E November 21, 2023 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 18, 2023 · Infection Control
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Potential for harm · D November 21, 2023 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected November 22, 2023 · Environmental
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Potential for harm · D November 30, 2022
Reasonably accommodate the needs and preferences of each resident.
Corrected December 1, 2022 · Resident Rights
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Potential for harm · D November 30, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 6, 2022 · Resident Assessment and Care Planning
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Potential for harm · E November 30, 2022
Observe each nurse aide's job performance and give regular training.
Corrected December 19, 2022 · Nursing and Physician Services
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Potential for harm · E November 30, 2022
Provide and implement an infection prevention and control program.
Corrected December 28, 2022 · Infection Control
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 5, 2025 | Fine | $14,901 |
| January 5, 2025 | Fine | $14,901 |
| August 27, 2024 | Fine | $9,872 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676388 · certified since August 3, 2015. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.