THE PAVILION AT CREEKWOOD
Grade F — 60/100 composite score
CMS Star Ratings
Certified Beds
126
Ownership
For profit - Limited Liability company
Total Fines
$39,674
Last Survey
N/A
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Staffing Hours & Turnover
Hours per Resident per Day (PBJ)
Turnover Rates
Ownership
THI OF TEXAS LLC
100%
HUNT VALLEY HOLDINGS LLC
THI OF BALTIMORE, INC.
FORMAN, MURRAY
THI OF TEXAS LLC
LEBLANC, RYAN
LEBLANC, RYAN
Penalties & Fines (3)
| Date | Type | Description | Amount |
|---|---|---|---|
| Jan 5, 2025 | Fine | — | $14,901 |
| Jan 5, 2025 | Fine | — | $14,901 |
| Aug 27, 2024 | Fine | — | $9,872 |
Health Inspection Deficiencies (24)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
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
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
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
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies
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
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
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
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
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
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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.