THE PAVILION AT CREEKWOOD

2100 CANNON DR
MANSFIELD, TX, 76063
8177796500
CCN: 676388
1
Overall
2
Health
1
Staffing
4
Quality
ChainFUNDAMENTAL HEALTHCARE
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
THI OF TEXAS LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
HUNT VALLEY HOLDINGS LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
THI OF BALTIMORE, INC.5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
FORMAN, MURRAY5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
LEBLANC, RYANCORPORATE OFFICERNOT APPLICABLE
THI OF TEXAS LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LEBLANC, RYANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (2)
DateTypeAmount
2025-01-05Fine$15K
2024-08-27Fine$10K
Health Deficiencies (22)
2025-08-06 · Health
E
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-02-26 · Health
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F585 · Resident Rights 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.
2025-01-05 · Health
J
F742 · 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.
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
J
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-08-27 · Health
J
F578 · Resident Rights 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.
2024-05-20 · Health
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2024-01-25 · Health
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2023-12-12 · Health
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
2023-11-21 · Health
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2023-03-21 · Health
D
F761 · Pharmacy Service 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.
2022-11-30 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F730 · Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.18
3.68
RN Hrs/Resident/Day
0.42
0.54
LPN Hrs/Resident/Day
0.93
0.81
CNA Hrs/Resident/Day
1.83
2.33
PT Hrs/Resident/Day
0.02
0.12
Data as of 2026-03-01