The Pavilion at Creekwood
2100 Cannon Dr, Mansfield, TX 76063
The Pavilion at Creekwood is a nursing home in Mansfield, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionApril 14, 2026 (6 months ago)
- Health citations since November 21, 202326 (Texas average 28)
- Fines in the past three years3, $39,674 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on August 28, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS has cited this home for F0755 4 times since 2024.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on June 1, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 2, 2026.
CMS has cited this home for F0689 2 times since 2025.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on April 14, 2026
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 15, 2026.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 15, 2026.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 15, 2026.
CMS has cited this home for F0812 2 times since 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 15, 2026.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on April 8, 2026.
CMS has cited this home for F0558 2 times since 2024.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on April 15, 2026.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 15, 2026.
Fire safety inspection on April 14, 2026
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation E0009. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on May 7, 2026.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 22, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 15, 2026.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on May 4, 2026.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 24, 2026.
CMS has cited this home for K0918 2 times since 2025.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on May 4, 2026.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Fine
CMS changed the fine from January 5, 2025 from $29,803 to $14,901.
Health inspection on August 6, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0686. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on August 7, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 7, 2025.
CMS has cited this home for F0684 2 times since 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of June 25, 2025
Fine
CMS changed the fine from August 27, 2024 from $12,340 to $9,872.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 1 of 5.
Health inspection on February 26, 2025
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 27, 2025.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 27, 2025.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on February 27, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 27, 2025.
Fire safety inspection on February 26, 2025
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 17, 2025.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on February 27, 2025.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 27, 2025.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Health inspection on January 5, 2025
3 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $14,901 on January 5, 2025.
CMS fine of $14,901 on January 5, 2025.
Show the 3 citations
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 6, 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 6, 2025.
Citation F0742. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 6, 2025.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on August 27, 2024
1 citationCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $9,872 on August 27, 2024.
Show the 1 citation
Citation F0578. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 28, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on May 20, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 21, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on May 21, 2024.
Health inspection on January 25, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 27, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on January 27, 2024.
Fire safety inspection on January 25, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on February 26, 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on February 26, 2024.
Health inspection on December 12, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on December 13, 2023.
Health inspection on November 21, 2023
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 18, 2023.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on November 22, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (817) 779-6500
- Last standard health inspection
- April 14, 2026 (6 months ago)
- Certified beds
- 126
- Residents per day, on average
- 93.9
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Mansfield Long Term Care, LLC
- Chain
- Fundamental Healthcare
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (26 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- THI OF TEXAS LLCOperational/managerial control · not applicable · since 06/21/2007
- LEBLANC, RYANOperational/managerial control · not applicable · since 01/01/2022
Questions
When was The Pavilion at Creekwood last inspected?
CMS lists April 14, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does The Pavilion at Creekwood have?
CMS lists 26 health citations since November 21, 2023. CMS also calls these deficiencies.
Has The Pavilion at Creekwood been fined?
CMS lists 3 fines in the past three years, $39,674 in total.
What is the CMS star rating of The Pavilion at Creekwood?
Its CMS overall star rating is 2 of 5.
Is The Pavilion at Creekwood a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.