Federal inspection record · CMS data as of October 1, 2026
The Pavilion At Creekwood
2100 Cannon Dr, Mansfield, TX · (817) 779-6500
- Certified beds
- 126
- Residents per day
- 94
- Ownership
- For-Profit
- Chain
- Fundamental Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- August 3, 2015
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
The Pavilion At Creekwood carries 119.75 inspection points. That is fewer than 27% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
26 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (4)
-
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
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.
-
J
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.
Everything else, by area of care
Pharmacy Service8E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
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.
- D
Ensure that residents are free from significant medication errors.
- E
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Quality of Life and Care4E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Resident Rights4D
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
Reasonably accommodate the needs and preferences of each resident.
Nutrition and Dietary2F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning2D
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Infection Control1E
- E
Provide and implement an infection prevention and control program.
Environmental1D
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspection history
2026-04-14
9 health deficiencies · 6 fire-safety deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2025-02-26
9 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2024-01-25
8 health deficiencies · 2 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 11 min of nursing staff time a day, 18 min of it from a registered nurse.
This home
3 h 11 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 42% of nursing staff and 54% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$39,674 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-01-05 | Fine | $14,901 |
| 2025-01-05 | Fine | $14,901 |
| 2024-08-27 | Fine | $9,872 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.2 pts worse | 2.2 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.5 pts better | 1.5 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.6 pts better | 100.0% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3 pts better | 100.0% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.5 pts better | 2.7% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.3 pts better | 2.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.5 pts better | 0.4% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication9 pts better | 8.8% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.7 pts better | 3.1% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened15.9 pts worse | 28.8% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased2 pts better | 13.8% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladderAbout the same | 0.3% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2.3 pts worse | 14.8% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.2 pts better | 2.5% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine10 pts better | 98.7% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.6 pts better | 10.6% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine0.7 pts better | 86.1% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission7 pts better | 18.5% | 25.5% | 23.4% |
·
Who owns and runs it
7 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Fundamental Administrative Services LLC | Adp Of The SNF · Organization | 0% | 18 facilities |
| Fundamental Clinical And Operational Services, LLC | Adp Of The SNF · Organization | 0% | 18 facilities |
| Leblanc, Ryan | Corporate Officer · Individual | 0% | 1 facilities |
| Leblanc, Ryan | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Leblanc, Ryan | Adp Of The SNF · Individual | 0% | 1 facilities |
| Rigsby, Camelia | Adp Of The SNF · Individual | 0% | 1 facilities |
| Thi Of Texas LLC | Operational/Managerial Control · Organization | 0% | 2 facilities |
·
Fire safety
11 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke6F
- F
Provide properly protected cooking facilities.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Gas, Vacuum, and Electrical Systems2F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Emergency Preparedness1F
- F
Include a process for Emergency Preparedness collaboration.
Services1F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Egress1E
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
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-
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