Nursing homes › Texas › The Pavilion at Creekwood
2100 Cannon Dr, Mansfield, TX 76063 · 8177796500 · 126 certified beds
Per CMS filings, this facility is affiliated with Fundamental Healthcare, a group operating 67 facilities in 6 states. Group record: average rating 2.4/5, 6 abuse citation icons, 3 facilities on the Special Focus list, $2,196,040 in federal fines. This facility rates below its group average (2.4/5).
Total nurse staffing: 3.21 (Texas median: 3.27). RN hours: 0.38. Weekend total: 2.81. Nursing staff turnover: 47%.
All-time on record: 24 deficiency citations, including 4 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-04-14 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Health | corrected 2026-04-15 |
| 2026-04-14 | 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. | E | Health | corrected 2026-04-15 |
| 2026-04-14 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2026-04-15 |
| 2026-04-14 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Health | corrected 2026-04-15 |
| 2026-04-14 | Reasonably accommodate the needs and preferences of each resident. | D | Health | corrected 2026-04-08 |
| 2026-04-14 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Health | corrected 2026-04-15 |
| 2026-04-14 | Ensure that residents are free from significant medication errors. | D | Health | corrected 2026-04-15 |
| 2025-08-06 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E | complaint | corrected 2025-08-07 |
| 2025-08-06 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2025-08-07 |
| 2025-02-26 | Ensure medication error rates are not 5 percent or greater. | E | Health | corrected 2025-02-27 |
| 2025-02-26 | 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 | Health | corrected 2025-02-27 |
| 2025-02-26 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Health | corrected 2025-02-27 |
| 2025-02-26 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Health | corrected 2025-02-27 |
| 2025-01-05 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J | complaint | corrected 2025-01-06 |
| 2025-01-05 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | complaint | corrected 2025-01-06 |
| 2025-01-05 | 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 | complaint | corrected 2025-01-06 |
| 2024-08-27 | 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. | J | complaint | corrected 2024-08-28 |
| 2024-05-20 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | complaint | corrected 2024-05-21 |
| 2024-05-20 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | complaint | corrected 2024-05-21 |
| 2024-01-25 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Health | corrected 2024-01-27 |
| 2024-01-25 | Reasonably accommodate the needs and preferences of each resident. | D | Health | corrected 2024-01-27 |
| 2023-12-12 | Provide safe and appropriate respiratory care for a resident when needed. | D | complaint | corrected 2023-12-13 |
| 2023-11-21 | Provide and implement an infection prevention and control program. | E | complaint | corrected 2023-12-18 |
| 2023-11-21 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | complaint | corrected 2023-11-22 |
| Date | Type | Amount |
|---|---|---|
| 2025-01-05 | Fine | $14,901 |
| 2025-01-05 | Fine | $14,901 |
| 2024-08-27 | Fine | $9,872 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| LEBLANC, RYAN | Corporate Officer | Individual | NOT APPLICABLE | since 01/01/2022 |
| THI OF TEXAS LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 06/21/2007 |
| LEBLANC, RYAN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 01/01/2022 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 676388. Corrections: data@carerecords.org.