Public Record
The Pavilion at Creekwood
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 126
- Avg. residents per day
- 93.9
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 32
- Inspections on file
- 13
- Last inspection
- 2025-08-06
*CMS
*CMS
*CMS
Citations
32 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0585Generalpotential for harm
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.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0742Seriousimmediate jeopardy
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.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0578Seriousimmediate jeopardy
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.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0761Generalpotential for harm
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.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0342Generalpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection2 deficiencies
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to provide…
Read full statement of deficiencies - View inspection reportInspection7 deficiencies
- Inspection7 deficiencies
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS…
Read full statement of deficiencies - Inspection3 deficiencies
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to…
Read full statement of deficiencies - Inspection1 deficiency
F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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. **NOTE- TERMS IN…
Read full statement of deficiencies - Inspection2 deficiencies
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on…
Read full statement of deficiencies - Inspection4 deficiencies
F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had…
Read full statement of deficiencies - View inspection reportInspection4 deficiencies
- Inspection1 deficiency
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure…
Read full statement of deficiencies - Inspection2 deficiencies
F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and…
Read full statement of deficiencies
Showing the 10 most recent inspections. 3 earlier inspections are also on record.
FAQ
Questions and answers
- What is The Pavilion at Creekwood?
- The Pavilion at Creekwood is a Medicare- and Medicaid-certified nursing home in Mansfield, TX, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 676388.
- What is the CMS rating for The Pavilion at Creekwood?
- The Pavilion at Creekwood has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does The Pavilion at Creekwood have?
- The Pavilion at Creekwood is certified for 126 beds. It serves an average of 93.9 residents per day.
- How many citations does The Pavilion at Creekwood have?
- The Pavilion at Creekwood has 32 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was The Pavilion at Creekwood last inspected?
- The Pavilion at Creekwood was last inspected on August 6, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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