nursing home in Mansfield, TX
The Pavilion at Creekwood
2100 Cannon Dr, Mansfield, TX 76063 · (817) 779-6500
★★★★★2
Below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★2
- Staffing★★★★★2
- Quality measures★★★★★4
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
The Pavilion at Creekwood at a glance
The Pavilion at Creekwood is a 126-bed for-profit nursing home in Mansfield, Texas (Tarrant County).
CMS gives it 2 out of 5 stars on its overall star rating, worse than the Texas average of 2.7.
Residents receive about 3.2 hours of nursing care per day (0.4 of them from registered nurses), worse than the state average of 3.4 hours.
Its most recent standard health inspection (April 14, 2026) found 8 health citations. The Texas average is 9.4.
Federal regulators fined it 3 times in the past three years, totaling $39,674.
Nursing staff turnover is 47% per year (state average 55.3%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Limited Liability Company
- Beds
- 126
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Fundamental Healthcare
- Medicare-certified since
- August 3, 2015
- Resident/family council
- Resident
- County
- Tarrant County
- CMS Certification Number
- 676388
Ratings
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 2 / 5 | 2.7 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 2 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 2 / 5 | 1.9 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 4 / 5 | 3.7 / 5 | 3.6 / 5 | Average |
| Long-stay quality rating (higher is better) | 4 / 5 | 4 / 5 | 3.8 / 5 | Average |
| Short-stay (rehab) quality rating (higher is better) | 5 / 5 | 3.2 / 5 | 3.3 / 5 | Better |
Staffing
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.21 hrs | 3.39 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.38 hrs | 0.43 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 1.89 hrs | 2.01 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 2.81 hrs | 2.98 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 47% | 55.3% | 45.8% | Average |
| Registered nurse turnover (yearly) (lower is better) | 35.7% | 54.6% | 42.9% | Better |
| Administrators who left in the past year (lower is better) | 0 | 1 | 1 | Better |
Inspections
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 8 | 9 | 9 | Better |
| Citations from complaint investigations (latest cycle) (lower is better) | 1 | 4 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 116.8 | 102 | 80.6 | Worse |
Penalties
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 3 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $39,674 | $44,141 | $30,972 | Worse |
| All federal penalties in the past 3 years (lower is better) | 3 | 2 | 1 | Worse |
Size
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 126 | 113 | 107 | |
| Average residents per day | 97 | 76 | 86 | |
| Occupancy | 77.2% | 67.6% | 80.9% |
Long-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 2.7% | 3.3% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 3.5% | 3.8% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 4.2% | 9.6% | 15.4% | Better |
| Long-stay residents with a urinary tract infection (lower is better) | 0% | 0.8% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0.3% | 0.3% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 15.2% | 15.8% | 13.9% | Worse |
| Long-stay residents whose walking worsened (lower is better) | 32.1% | 14% | 14.1% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 0.9% | 3% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 1.9% | 2.4% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 10.4% | 18% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 13.4% | 13.4% | 19% | Better |
| Long-stay residents given a flu vaccine (higher is better) | 97.2% | 98% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 100% | 96.6% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 0.1% | 1.5% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 98.9% | 88% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 98.8% | 88.9% | 82% | Better |
Inspection citations
State inspectors cited this home for 25 health deficiencies and 11 fire safety deficiencies in the inspection records CMS currently publishes. 4 citations involved actual harm, including 4 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| June 1, 2026 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected June 2, 2026 |
| April 14, 2026 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected April 24, 2026 |
| April 14, 2026 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected April 15, 2026 |
| April 14, 2026 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | F Potential harm, widespread | Corrected May 4, 2026 |
| April 14, 2026 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | F Potential harm, widespread | Corrected April 22, 2026 |
| April 14, 2026 Fire safety | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Tag E0009 | F Potential harm, widespread | Corrected May 7, 2026 |
| April 14, 2026 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | E Potential harm, pattern | Corrected May 4, 2026 |
| April 14, 2026 Standard | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected April 15, 2026 |
| April 14, 2026 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected April 15, 2026 |
| April 14, 2026 Standard | 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 · Tag F0761 | E Potential harm, pattern | Corrected April 15, 2026 |
| April 14, 2026 Standard | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected April 15, 2026 |
| April 14, 2026 Standard | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Tag F0636 | D Potential harm, isolated | Corrected April 15, 2026 |
| April 14, 2026 Standard | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | D Potential harm, isolated | Corrected April 8, 2026 |
| April 14, 2026 Standard | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected April 15, 2026 |
| August 6, 2025 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | E Potential harm, pattern | Corrected August 7, 2025 |
| August 6, 2025 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected August 7, 2025 |
| February 26, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected March 17, 2025 |
| February 26, 2025 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | E Potential harm, pattern | Corrected February 27, 2025 |
| February 26, 2025 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | E Potential harm, pattern | Corrected February 27, 2025 |
| February 26, 2025 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | E Potential harm, pattern | Corrected February 27, 2025 |
| February 26, 2025 Standard | 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 · Tag F0585 | D Potential harm, isolated | Corrected February 27, 2025 |
| February 26, 2025 Standard | 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 · Tag F0655 | D Potential harm, isolated | Corrected February 27, 2025 |
| February 26, 2025 Standard | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected February 27, 2025 |
| January 5, 2025 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | J Immediate jeopardy, isolated | Corrected January 6, 2025 |
| January 5, 2025 Complaint | 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 · Tag F0742 | J Immediate jeopardy, isolated | Corrected January 6, 2025 |
| January 5, 2025 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | J Immediate jeopardy, isolated | Corrected January 6, 2025 |
| August 27, 2024 Complaint | 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 · Tag F0578 | J Immediate jeopardy, isolated | Corrected August 28, 2024 |
| May 20, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected May 21, 2024 |
| May 20, 2024 Complaint | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | D Potential harm, isolated | Corrected May 21, 2024 |
| January 25, 2024 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | E Potential harm, pattern | Corrected February 26, 2024 |
| January 25, 2024 Fire safety | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Tag K0374 | E Potential harm, pattern | Corrected February 26, 2024 |
| January 25, 2024 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected January 27, 2024 |
| January 25, 2024 Standard | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | D Potential harm, isolated | Corrected January 27, 2024 |
| December 12, 2023 Complaint | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected December 13, 2023 |
| November 21, 2023 Complaint · Infection control | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected December 18, 2023 |
| November 21, 2023 Complaint | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Tag F0919 | D Potential harm, isolated | Corrected November 22, 2023 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 2 federal penalties in the past three years, including $24,773 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| January 5, 2025 | Fine | $14,901 |
| August 27, 2024 | Fine | $9,872 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| FUNDAMENTAL ADMINISTRATIVE SERVICES LLC Organization | adp of the snf | NOT APPLICABLE | 07/01/2007 |
| FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLC Organization | adp of the snf | NOT APPLICABLE | 07/01/2007 |
| LEBLANC, RYAN Individual | adp of the snf | NOT APPLICABLE | 01/01/2022 |
| RIGSBY, CAMELIA Individual | adp of the snf | NOT APPLICABLE | 12/01/2016 |
| LEBLANC, RYAN Individual | corporate officer | NOT APPLICABLE | 01/01/2022 |
| LEBLANC, RYAN Individual | operational/managerial control | NOT APPLICABLE | 01/01/2022 |
| THI OF TEXAS LLC Organization | operational/managerial control | NOT APPLICABLE | 06/21/2007 |
Other nursing homes near The Pavilion at Creekwood
Avir at Mansfield
1402 E. Broad St., Mansfield, TX 76063 · 1.7 mi
For-profit · 127 beds · Part of Avir Health Group
★★★★★4Above averageMansfield Medical Lodge
301 N Miller Rd, Mansfield, TX 76063 · 2.1 mi
For-profit · 118 beds · Part of Priority Management
★★★★★4Above averageMatlock Place Health & Rehabilitation Center
7100 Matlock Road, Arlington, TX 76002 · 3.8 mi
For-profit · 148 beds
★★★★★1Much below averageArbrook Plaza
401 West Arbrook Blvd., Arlington, TX 76014 · 7.5 mi
For-profit · 120 beds · Part of Hmg Healthcare
★★★★★3AverageTown Hall Estates - Arlington, INC.
824 W Mayfield Rd, Arlington, TX 76015 · 8 mi
Non-profit · 116 beds
★★★★★2Below averageAvir at Kennedale
413 Mansfield Cardinal Road, Kennedale, TX 76060 · 8.4 mi
For-profit · 58 beds · Part of Avir Health Group
- New owner (last 12 months)
★★★★★1Much below average
Frequently asked questions
What is The Pavilion at Creekwood's rating?
The Pavilion at Creekwood has 2 out of 5 stars on the CMS overall star rating. The average for Texas nursing homes is 2.7 stars.
How many inspection citations did The Pavilion at Creekwood receive?
Its most recent standard health inspection found 8 citations, compared with a Texas average of 9.4. Every citation is listed on this page with its severity.
Does The Pavilion at Creekwood accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns The Pavilion at Creekwood?
It is for profit - limited liability company and part of Fundamental Healthcare. The ownership section on this page lists the owners and managers reported to CMS.
Where is The Pavilion at Creekwood and how do I contact it?
The Pavilion at Creekwood is at 2100 Cannon Dr, Mansfield, TX 76063. Phone: (817) 779-6500.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.