F60

THE PAVILION AT CREEKWOOD

Grade F 60/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
4/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

126

Ownership

For profit - Limited Liability company

Total Fines

$39,674

Last Survey

N/A

2100 CANNON DR, MANSFIELD, TX 76063
8177796500

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.41h
LPN
0.90h
CNA
1.77h
Total
3.09h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

THI OF TEXAS LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jun 2007

100%

HUNT VALLEY HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Feb 2010

THI OF BALTIMORE, INC.

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jul 2007

FORMAN, MURRAY

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Mar 2006

THI OF TEXAS LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jun 2007

LEBLANC, RYAN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2022

LEBLANC, RYAN

IndividualCORPORATE OFFICERSince Jan 2022

Penalties & Fines (3)

$39,674total fines
DateTypeDescriptionAmount
Jan 5, 2025Fine$14,901
Jan 5, 2025Fine$14,901
Aug 27, 2024Fine$9,872

Health Inspection Deficiencies (24)

August 6, 2025Health2 deficiencies
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Aug 7, 2025
0686EMinimal harm, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Aug 7, 2025
February 26, 2025Health4 deficiencies
0585DMinimal 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.

Resident Rights Deficiencies

Corrected Feb 27, 2025
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Feb 27, 2025
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Feb 27, 2025
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Feb 27, 2025
January 5, 2025Health3 deficiencies3 severe
0684JImmediate jeopardy, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jan 6, 2025
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jan 6, 2025
0742JImmediate jeopardy, 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.

Quality of Life and Care Deficiencies

Corrected Jan 6, 2025
August 27, 2024Health1 deficiency1 severe
0578JImmediate jeopardy, 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.

Resident Rights Deficiencies

Corrected Aug 28, 2024
May 20, 2024Health2 deficiencies
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected May 21, 2024
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected May 21, 2024
January 25, 2024Health2 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Jan 27, 2024
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jan 27, 2024
December 12, 2023Health1 deficiency
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Dec 13, 2023
November 21, 2023Health2 deficiencies
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 18, 2023
0919DMinimal harm, Isolated

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected Nov 22, 2023
March 21, 2023Health1 deficiency
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Mar 22, 2023
February 16, 2023Health2 deficiencies
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Feb 21, 2023
0686EMinimal harm, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Mar 7, 2023
November 30, 2022Health4 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Dec 1, 2022
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 6, 2022
0730EMinimal harm, Pattern

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Dec 19, 2022
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 28, 2022

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Frequently Asked Questions

What is the CareGrader rating for THE PAVILION AT CREEKWOOD?

THE PAVILION AT CREEKWOOD in MANSFIELD, Texas has a CareGrader grade of F (Poor), with a composite score of 59.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for THE PAVILION AT CREEKWOOD?

THE PAVILION AT CREEKWOOD has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does THE PAVILION AT CREEKWOOD have?

THE PAVILION AT CREEKWOOD has 24 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has THE PAVILION AT CREEKWOOD been fined?

Yes. THE PAVILION AT CREEKWOOD has $39,674 in total fines from CMS enforcement actions across 3 penalties.

How many beds does THE PAVILION AT CREEKWOOD have?

THE PAVILION AT CREEKWOOD has 126 certified beds with approximately 99 current residents (79% occupancy). The facility is located at 2100 CANNON DR, MANSFIELD, Texas 76063. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.