Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances
residents had and ensure that all written grievance decisions include the date the grievance was received,
a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary
of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the
grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a
result of the grievance, and the date the written decision was issued for one (Resident #99) of five residents
reviewed for grievances.
The facility failed to document any attempts to resolve Resident #99's grievance when she expressed
concern that CNA G refused to provide incontinent care.
This failure could place residents at risk of a diminished quality of life and unmet care needs.
Findings included:
Review of Resident #99's Face Sheet, dated 02/26/25, reflected she was a [AGE] year-old female who
admitted to the facility on [DATE], with diagnoses including diverticulitis of large intestine with perforation
and abscess with bleeding (a serious condition that can occur when a small pouch in the colon wall
becomes inflamed and/or infected) and anxiety disorder (a mental health condition that involves excessive
fear, worry, or dread).
Review of Resident #99's MDS Assessment, dated 12/23/24, reflected she was cognitively intact. Resident
#99 was identified as being occasionally incontinent of bladder and frequently incontinent of bowel.
Review of Resident #99's Care Plan, dated 12/26/24, reflected she was identified as being incontinent of
bladder and bowel. A documented approach for this care area was for staff to assist with toilet use and
provide incontinent care as indicated.
Review of Grievance Reports from 01/01/25 to 02/24/25 reflected no evidence that a grievance related to
the allegation made by Resident #99 had been filed.
During an interview with Resident #99 on 02/24/25 at 2:00PM, she stated within the past several weeks,
there was a singular instance when CNA G, who worked the night shift, refused to change her brief.
Resident #99 stated she told ADON E about the issue, and ADON E stated she would take care of it.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
676388
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a telephone interview with ADON E on 02/24/25 at 2:53PM, she stated Resident #99 did tell her
about an instance in which CNA G refused to change her brief on an overnight shift. She stated Resident
#99 felt as though this was a customer service issue; she did not report feeling as though she had been
abused or neglected. ADON E stated she spoke with CNA G regarding this customer service issue and the
need to provide timely incontinent care, but she did not file a formal grievance. ADON E stated looking
back, she should have filed a grievance on behalf of the resident.
During an interview with the Administrator on 02/24/25 at 3:30PM, he stated prior to today (02/24/25), he
had not been made aware of the incident in which CNA G allegedly refused to provide incontinent care for
Resident #99. The Administrator stated once ADON E became aware of the alleged incident, she should
have filed a grievance form on behalf of Resident #99. The Administrator stated the risk of a grievance not
being filed included the facility not being able to investigate and resolve resident concerns/complaints.
The surveyor attempted to contact CNA G via telephone on 02/24/25 at 4:22PM. The surveyor left a voice
message requesting a return telephone call.
Review of the facility's Complaints/Grievances Process policy, dated 11/06/23, reflected, .Procedures: 1.
Grievances/Complaints are accepted by the following, but not limited to: A. Administrator B. Department
manger or his/her designee C. Supervisors D. Unit Managers E. Ombudsman 2. Upon receipt of the
grievance the receiver completes all appropriate sections of electronic Grievance form under Portal Links or
a paper form .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop and implement a baseline care plan for each
resident that included instructions needed to provide effective and person-centered care for the resident
that met professional standards of care within 48 hours of the resident's admission for one (Resident #99)
of five residents reviewed for baseline care plans.
The facility failed to complete a baseline care plan for Resident #99.
This failure could place newly admitted residents at risk of not receiving effective and person-centered care
and services.
Findings included:
Review of Resident #99's Face Sheet, dated 02/26/25, reflected she was a [AGE] year-old female who
admitted to the facility on [DATE], with diagnoses including diverticulitis of large intestine with perforation
and abscess with bleeding (a serious condition that can occur when a small pouch in the colon wall
becomes inflamed and/or infected) and anxiety disorder (a mental health condition that involves excessive
fear, worry, or dread).
Review of Resident #99's MDS Assessment, dated 12/23/24, reflected she was cognitively intact.
Review of Resident #99's electronic medical records on 02/25/25 reflected no evidence that a baseline
Care Plan had been completed.
During an interview with MDS Coordinator F on 02/26/25 at 10:10AM, she stated she was responsible for
completing baseline Care Plans for residents within 48 hours of their admission to the facility. She
confirmed there was no evidence to suggest that a baseline Care Plan for Resident #99 had been
completed following her admission. MDS Coordinator F stated the risk of not completing a baseline Care
Plan for a resident within the required timeframe was that the facility would receive a citation from the State.
Review of the facility's Care Plan Process, Person-Centered Care policy, dated 05/05/23, reflected,
.Procedures: .1: Develop and implement the baseline person-centered care plan within 48 hours of a
resident's admission .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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
interview, and record review, the facility failed to provide pharmaceutical services (including procedures that
assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to
meet the needs of each resident for 1 (Resident #99) of 40 resident reviewed for pharmacy services.
The facility failed to ensure the 400 Hall nurses' medication cart had an accurate narcotic count for
Resident #99.
This failure could place residents at risk for medication errors, drug diversion, and delays in medication
administration.
Findings included:
Record review of Resident# 99's face sheet dated 02/26/25 reflected the resident was a [AGE] year-old
female admitted to the facility on [DATE]. Admitting diagnoses included diverticulitis of large intestine with
perforation and abscess with bleeding, cough, depressive episodes, allergy, GERD, without bleeding,
nausea with vomiting, sepsis (a life-threatening condition that occurs when the body's immune system
overreacts to an infection ), anemia, unspecified and HT
Record review of Resident #99's admission MDS Assessment, dated 12/23/24, reflected the resident BIMS
score of 15 indicating no cognitive impairment.
Record review of Resident #99's care plan did not indicate the resident was taking pain medications.
Record review of Resident #99's physician's orders dated February 2025, reflected an order for the resident
to receive Hydrocodone-Acetaminophen Oral Tablet 10-325 MG. Give 1 tablet by mouth every 6 hours as
needed for pain. Acetaminophen with codeine #3 (Tylenol with codeine #3). Give 1 tablet by mouth every 4
hours as needed for pain.
Record review of Resident #99's medication administration record reflected, Hydrocodone-Acetaminophen
Oral Tablet 10-325 MG was last administered on 01/22/25 and Acetaminophen with codeine #3 was last
administered on 2/15/25.
Review of the narcotic log for Resident #99 reflected the count sheet for Acetaminophen with codeine was
19 and the medication card contained 20 tablets and the narcotic sheet for Hydrocodone-Acetaminophen
10-325 MG was 20 and the card contained 19 tablets.
In an interview on 02/26/25 at 10:35 AM with LVN C, she stated she had not administered any pain
medication to Resident #99. LVN C stated she was switched to work on the hall after the start of the shift
and ADON D was the one who completed the narcotics count with the night nurse. LVN C stated she did
not complete a narcotic count after taking over the cart from the ADON D. LVN C stated she would inquire
from the ADON if she administered the pain medication. LVN C stated she last worked on the hall on
02/24/25 and she did not realize the count was wrong. LVN C stated she was supposed to make sure the
name of the resident, the medication and the count all matched. LVN C stated with any narcotics
discrepancies, she was expected to report immediately to the DON.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 02/26/25 at 10:42 AM with ADON D, she stated she had not administered any pain
medication to Resident #99. ADON D stated when she completed the count during the change of shift, the
count was correct, but per the records, did not reveal to be correct. Then the ADON stated she would inform
the DON of the discrepancy. The ADON stated during narcotic count she was supposed to check and make
sure the medication and number of the narcotics in the narcotic sheet were a match.
Residents Affected - Few
In an interview on 02/26/25 at 10:56 AM with Resident #99, she stated she was not in pain, and she had
not taken any pain medication on 02/26/25. Resident #99 stated she took a hydrocodone-Acetaminophen
10-325 mg tablet about two weeks ago due to pain from surgery, and since then she had not taken any
pain medication.
An interview on 02/26/25 at 2:35 PM with the DON revealed she had been made aware of the narcotic
discrepancy on hall 400 nurse medication cart, and she was already in the process of in-servicing the staff.
The DON stated she talked with Resident #99, and the resident stated she had taken Norco and not Tylenol
#3 when she had requested for a pain medication about two weeks ago. The DON stated when she talked
with the nurse on duty, the nurse had given the resident the Norco and signed in the wrong narcotic sheet.
The DON stated the charge nurse had failed to realize the inconsistency and get it corrected timely. The
DON stated she expected the charge nurse to make sure the medication, the resident name and narcotic
count matched when they completed narcotic count during shift change to prevent narcotics discrepancy.
Review of the facility's policy undated and titled medication management program reflected, . Security and
Safety Guidelines . 9. Controlled substances are accounted for each patient/resident on a Controlled
Substance Record . A. Substances are counted by authorized staff members at each change of shift.
B. Drug count discrepancies are reported immediately for the Director of Nursing or designee.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%,
for 45 medication administration opportunities with 11 errors resulting in a 24% medication error rate, for 2
of 6 residents (Residents #52 and #65) reviewed for medication administration.
Residents Affected - Some
1. The facility failed to ensure MA A administered a medication as ordered to Resident #52 by crushing
Nifedipine ER (used to treat hypertension (high blood pressure) and angina (chest pain)); a medication that
should not be crushed.
2. The facility failed to ensure MA B administered Resident #65 medication per physician orders,
medications scheduled at 7 am were administered at 11:18 am
This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and
possible adverse reactions.
The findings included:
Record review of Resident #52's admission record dated 02/26/2025 revealed an admission date of
11/05/22 with diagnoses which included Muscle wasting and atrophy, Dysphagia, HTN, hypertensive heart
disease without heart failure, schizophrenia, and Type 2 diabetes mellitus.
Record review of Resident #52's quarterly assessment MDS dated [DATE] revealed Resident #52 had a
BIMS score of 05, indicating severe cognitive impairment.
Record review of Resident #52's care plan edited on 12/26/24 revealed, resident had hypertension, goal
will not experience any complications r/t blood pressure through next review period, approach, Administer
medications as ordered.
Record review of Resident #52's physicians orders dated February 2025 revealed the physician prescribed
for Resident #52 to receive the following medications:
Famotidine 10 mg 2 tablets
Divalproex sprinkle 125 mg 2 capsules
Benztropine 1 mg 1 tablet
Atenolol 50 mg 1 tablet
Clopidogrel 75 mg 1 tablet
Glimepiride 2 mg 1 tablet
Nifedipine ER 60 mg 1 tablet, NOT TO CRUSH
Observation on 02/26/25 at 11:01 AM, revealed MA A crushed and administered the following medications
to Resident #52:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Famotidine 10 mg 2 tablets
Level of Harm - Minimal harm
or potential for actual harm
Divalproex sprinkle 125 mg 2 capsules
Benztropine 1 mg 1 tablet
Residents Affected - Some
Atenolol 50 mg 1 tablet
Clopidogrel 75 mg 1 tablet
Glimepiride 2 mg 1 tablet
Nifedipine ER 60 mg 1 tablet
In an interview with MA A on 12/24/25 at 11:04 am, MA A stated the resident always took crushed
medications and he had been taking Nifedipine ER crushed. MA A stated per the medication instructions,
the medication was not supposed to be crushed. She stated the medication was extended-release meaning
required to be released gradually, and if it was crushed the medication could be absorbed at once which
could lead to medication overdose or side effects. MA A stated she would inform the charge nurse to get
the medication switched.
Record review of Resident #65's admission record dated 02/26/25 revealed an admission date of 01/06/25
with diagnoses which included, Cognitive communication deficit, chronic kidney disease stage 3, dementia,
psychotic disturbance, mood disturbance, and anxiety, osteoarthritis, vitamin deficiency, hyperlipidemia,
HTN acute on chronic diastolic (congestive) heart failure, pain, personal history of malignant neoplasm of
prostate (cancer of the prostate gland) and Type 2 diabetes mellitus.
Record review of Resident #65's quarterly assessment MDS dated [DATE] revealed Resident #65 had a
BIMS score of 07 indicating severe cognitive.
Record review of Resident #65's physicians orders dated February 2025 revealed the physician prescribed
Resident #65 to receive the following medications:
Amlodipine 5 mg at scheduled to be administered at 7am
Isosorbide mono ER 30 mg scheduled to be administered at 7am
Finasteride 5 mg scheduled to be administered at 7am
Memantine 10 mg scheduled to be administered at 7am
Montelukast 10 mg scheduled to be administered at 7am
Nebivolol 5 mg scheduled to be administered at 7am
Pantoprazole 40 mg scheduled to be administered at 7am
Tamsulosin 0.4 mg scheduled to be administered at 7am
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Clopidogrel 75 mg scheduled to be administered at 7am
Level of Harm - Minimal harm
or potential for actual harm
Aspirin 81 mg scheduled to be administered at 7am
Residents Affected - Some
Observation on 02/24/25 at 11:18 AM revealed MA B administered the following medications to Resident
#65.
Amlodipine 5 mg 1 tablet
Isosorbide mono ER 30 mg 1 tablet
Finasteride 5 mg 1 tablet
Memantine 10 mg 1 tablet
Montelukast 10 mg 1 tablet
Nebivolol 5 mg 1 tablet
Pantoprazole 40 mg 1 tablet
Tamsulosin 0.4 mg 1 tablet
Clopidogrel 75 mg 1 tablet
Aspirin 81 mg 1 tablet
In an interview on 02/26/25 at 11:05 AM with MA B, she stated she did administer the medications late
mainly because there was a lot of residents to administer medications to who were scheduled at the same
time. MA A stated she was supposed to follow the five rights of medication administration; that was the right
medication, time, dosage, patient, and route. MA A stated she had informed the DON not getting the
medication completed on time, and so far, nothing had been done. MA A stated Resident #65 was on blood
pressure medications thus requiring the medications to be administered on time to prevent increase in
blood pressure. MA A stated last month, the staff was in-serviced on making sure the medications were
administered on time.
In an interview on 02/26/25 at 02:22 PM with the DON, she stated MA B had informed her regarding the
medications being late and the issue will be addressed in the management meeting. The DON stated she
expected the staff to follow the medication administration protocol of administering medications one hour
before and one hour after the scheduled time, and following the physician orders. The DON stated MA A
was not supposed to crush extended-release medications because it would alter the potency of the
medications. The DON stated the staff were in-serviced on medication administration on 2/21/25.
Review of the facility's policy undated, titled management medication program, reflected The facility
implements the management medication program to meet the pharmaceutical needs of the patients and
residents, according to the established standards of practice and regulatory requirements.Preparing for
medication pass.7. Medications are administered not more than one (1) hour before to one (1) hour after
the designated medication pass time.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676388
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion at Creekwood
2100 Cannon Dr
Mansfield, TX 76063
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Administering the medication pass.F. Crush oral medications in accordance to the facility policy.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676388
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 citations recorded*CMS
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.
F585 - Grievances
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.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the February 26, 2025 survey of THE PAVILION AT CREEKWOOD?
This was a inspection survey of THE PAVILION AT CREEKWOOD on February 26, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE PAVILION AT CREEKWOOD on February 26, 2025?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grie..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.