Inspection·August 6, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few adherent devitalized necrotic tissue. There was 10% slough and 60% granulation tissue with no signs of infection. A surgical debridement (a wound care approach where dead or damaged tissue is removed repeatedly over time to promote healing) procedure was completed to remove necrotic tissue and establish the margins of viable tissue. As a result of this procedure, the nonviable tissue in the wound bed decreased from 40 percent to 10 percent. A second visit from the wound doctor occurred on 08/06/25 where Resident #1's wound had decreased in size and was 1.8 x 1.5 x 0.1 cm with a surface area of 2.70 cm and wound progress was noted to be improved as evidenced by decreased surface area with no pain and no signs of infection. The Dressing Treatment Plan reflected: Primary Dressing- 1) Add Collagen Powder once daily and as needed if saturated, soiled, or dislodged for 30 days; 2) Sodium Hypochlorite Gel (Anasept) once daily for 30 days and as needed: if saturated, soiled or dislodged for 30 days; Secondary Dressing: 1) Add Gauze Island w/ bdr once daily and as needed: if saturated, soiled, or dislodged for 30 days.Record review of Resident #1's physician order dated 07/30/25 reflected, Dressing Treatment Plan: Primary Dressing-Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged for 30 days. Secondary Dressing- Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged for 30 days.An observation of Resident #1 on 08/05/25 at 12:14 PM, revealed she was in the facility's courtyard with a family member being pushed in a wheelchair. Her feet were observed to not have any socks or shoes on either foot. Resident #1's left foot had an open wound about a quarter in size next to her great big toe and second toe. An interview with LVN A on 08/05/25 at 2:30 PM, revealed she was the charge nurse for Resident #1 from 6A-2P and was responsible for completing any wound care on her hall, since the wound care nurse was not at the facility that day. LVN A stated there was no dressing on Resident #1's wound on her foot because when she went to round on the resident earlier in the morning, she was indicating her foot was in pain so she took the dressing off her wound and gave her a pain pill. LVN A stated she decided to keep the dressing off and leave the wound open to air while the pain medication worked. LVN A stated, But then it got very busy and I was running back and forth. She stated Resident #1's family member then arrived for a visit and wanted to take the resident around the facility and outside. When the family left, LVN A stated that was when she covered Resident #1's wound with a dressing. LVN A stated Resident #1 had gangrene on her foot and the wound was supposed to always be covered, but she thought that since the resident was in pain earlier, leaving it off for a while would be okay. LVN A stated she should have tried to apply a dressing, however, when she initially removed it. LVN A stated having an open gangrene wound not covered with a dressing could place Resident #1 at risk for infection. She stated Resident #1 had just finished a round of antibiotics for an infection in that area. A record review of Resident #1's MAR reflected no pain medication was administered to her on the 6a-2p shift on 08/05/25, however, there was a follow up pain assessment by LVN A initialed at 9:30 AM from an earlier pain medication administration by the overnight nurse at 5:27 AM indicating it had been effective and her pain was controlled. A follow up interview with LVN A on 08/06/25 at 1:45 PM, revealed on 08/05/25, what had actually happened was when she got to work, she got her report from the overnight nurse and then around 6:30 am, one of her residents became unresponsive and she had to assess her and send her out to the hospital. LVN A also stated the facility was down one CNA for the halls she covered, so they had four instead of five, for 70 residents. While she was dealing with the other resident's emergency, she was walking down the hall and could hear Resident #1 crying so she went in to check on her. She said Resident #1 was saying leg my leg.my leg. LVN A said the dressing on her foot looked too tight so she took it off but then had to deal with the crisis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 2 of 7 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 08/06/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete related to the other resident on the hall and she was rushing to call 911. Then after that, another resident's family member came to visit and had an issue that LVN A had to deal with so we don't have any complaints, and then Resident #1's family member arrived for a visit. LVN A stated the family member about the dressing being off because she wanted to wheel her around the facility and go outside. LVN A stated, I said just tell me when you come back.Yesterday was so frustrating, usually when we work with four aides only, we have to help them feed, transfer and yesterday with two families present, I had to make sure those residents were okay. I didn't leave [Resident #1's] on purpose. LVN A confirmed the antibiotic that Resident #1 had just finished was for the infected wound on her foot and it was to be covered because, Anything in the air can get into the wound and infect it. An interview with the wound care nurse (WC-LVN D) on 08/06/25 at 1:15 PM, revealed Resident #1's wound started as a scratch between her toes and it was not gangrene, however, she did not know what the wound care doctor was considering it. She stated it was a split between the toes that occurred and due to the resident's poor circulation it worsened. WC LVN D stated her expectation was that LVN A should have provided Resident #1 pain medication if needed and redressed the wound immediately. Review of the facility's policy titled, Wound Care-Performing a Dressing Change revised June 2015 reflected, Policy- A dressing change will follow specific manufacturer's guidelines and general infection control principles; Procedures: .4. Assess the wound .6. Apply a cover dressing-date and initial cover dressing, place time reference on it. Event ID: Facility ID: 676388 If continuation sheet Page 3 of 7 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 08/06/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 review, the facility failed to ensure residents with pressure ulcers and at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #2, #3 and #4) of six residents reviewed for treatment/services for pressure ulcers.1. The facility failed to ensure pressure was offloaded from Resident #2's unstageable deep tissue injury on his left heel on 08/05/25. 2. The facility failed to ensure Resident #3's right heel air boot was in place to relieve and reduce pressure to a healing wound on 08/05/25.3. The facility failed to ensure pressure was offloaded on Resident #4's healing surgical incision site on her lower leg on 08/05/25.This failure placed residents at risk of worsening pressure and delayed healing, as well as discomfort and pain. Findings included:1. Record review of Resident #2's Face Sheet dated 08/06/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's diagnoses included metabolic encephalopathy (a condition where brain dysfunction arises from a chemical imbalance in the blood caused by an underlying medical condition or illness), diabetes mellitus (a chronic condition where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), atherosclerotic heart disease (plaque buildup in the arterial walls of the heart), muscle wasting and atrophy (loss of muscle mass and strength).Record review of Resident #2's admission MDS dated [DATE] reflected a BIMS score of 13, which indicated moderate cognitive impairment. He had no psychosis, delirium or rejection of care issues. Resident #2 had range of motion impairment on both sides of his lower extremities. Resident #2 was dependent on the physical assistance of staff for transfer and substantial/maximal assistance for bed mobility. Resident #2 was at risk of developing pressure ulcers and he had one unhealed and unstageable pressure injury presenting as a deep tissue injury upon admission. Resident #2 required pressure ulcer/injury care and applications of ointments/dressings. Record review of Resident #2's care plan dated 07/25/25 reflected, [Resident #2] has a DTI to his left heel related to immobility; At risk for Pressure Injury related to: impaired mobility, incontinence, diabetes, kidney failure, heart failure and fragile skin. Approaches included, Use pillows, pads, or other pressure-reduction devices to offset pressure from bony prominences.Record review of Resident #2's initial wound care visit dated 07/20/25 reflected he had an unstageable deep tissue injury of the left heel of undetermined thickness with a two-to-four-month time frame for healing, a goal to decrease the ulcer area, with approaches that included offloading. Resident #2's wound size was 7cmx10cmx not determinable, 70 cm in surface area, no exudate, skin with purple/maroon discoloration, blood filled blister, no pain and no signs/symptoms of infection. Recommendations included to float heels in bed, reposition per facility protocol and off-load wounds. A second visit was completed on 08/06/25 and the wound care doctor noted the resident's wound measurement were the same as the week prior and the wound progress was not at goal due to need more time. There was no pain or signs of infection on the second visit. Record review of Resident #2's physician order dated 07/25/2025 reflected, Elevate/Float Heels while in bed; Right plantar DTI- apply skin prep to area daily.Record review of Resident #2's nursing progress note dated 07/30/2025 reflected, Left heel DTI measuring 7cm x10cm- skin intact with purple/ maroon discoloration (blood filled blister), current wound care order continues. Resident continues wearing air boots in air boots as prescribed.An observation of Resident #2 on 08/05/25 at 2:08 PM, revealed Resident #2's feet were not offloaded and his heels were placed directly on a pillow at the foot of his bed. An interview with the DON on 08/05/25 at 2:09 PM, revealed she observed Resident #2 and he did not have his feet properly Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 4 of 7 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 08/06/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some offloaded. An interview with LVN E on 08/05/25 at 2:12 PM, revealed he was the charge nurse from 6a-2p for Resident #2. He stated he had not touched Resident #2's feet that shift so he did not know who placed his feet and heels directly on a pillow. LVN E stated he was the one who had completed wound care on Resident #2's heel that shift, but he was not sure if he required air boots and he was only there to provide the wound care and did not check to see if they were offloaded properly. He checked Resident #2's chart and verified air boots were ordered to be in use. Record review of new physician's order dated 08/05/25 (after investigator intervention), reflected, Z-flex boots to offload heels while in bed, Frequency: Every Shift.Record review of Resident #2's revised care plan (completed after investigator intervention), reflected the care plan was updated by the facility and reflected he was resistant to care. The care plan update on 08/06/25 reflected, Problem Start Date: 08/06/2025-[Resident #2] has behaviors AEB: resident unsafely puts himself into bed and doesn't apply boots to protect his heels- Approach: Document non-compliance in clinical record.Record review of Resident #2's nursing progress notes since his admission on [DATE], reflected no entries related to him being non-compliant with wearing any heel protectors/air boots. 2. Record review of Resident #3's Face Sheet dated 08/06/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3's diagnoses included metabolic encephalopathy (a condition where brain dysfunction arises from a chemical imbalance in the blood caused by an underlying medical condition or illness), muscle wasting and atrophy (loss of muscle mass and strength) and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, leading to damage to brain cells). Record review of Resident #3's admission MDS dated [DATE] reflected a BIMS score of 08, which indicated moderate cognitive impairment. Resident #3 had no psychosis, delirium or rejection of care issues. She was dependent on the physical assistance of staff for transfer and substantial/maximal assistance for bed mobility. Resident #3 was at risk of developing pressure ulcers/injuries but had no pressure ulcers documented as being present at the time of the assessment, as well as no venous or stasis ulcers. Resident #3 also had no other ulcers, wounds or skin problems indicated. Record review of Resident #3's care plan dated 07/07/25 reflected, 1) [Resident #3] is at risk for Pressure Injury related to: impaired mobility, incontinence, decreased cognition, kidney failure and fragile skin, 2) [Resident #3] has a current wound/disruption of skin surface: blood filled, blister Skin tear to RLL. Approaches included, Use pillows, pads, or other pressure-reduction devices to offset pressure from bony prominences.Record review of Resident #3's physician orders reflected, Offload right heel when resident is in bed every shift (start date 07/03/2025 -open ended).Record review of Resident #3's nursing progress note dated 07/16/25 reflected, Wound update- blister to right heel dry with blister surface continuing to slough off, application of betadine continues to area daily and offloading of heels. Wound surface area decreasing in size.An observation of Resident #3 on 08/05/25 at 1:50 PM, revealed she was in bed asleep. Resident #3's feet were observed to have no heel protectors or air boot on. All wound dressings were observed to be in place and was dated 08/05/25. An interview and observation on 08/05/25 at 2:03 PM, with LVN B revealed Resident #3 should have air boots on her feet and went to the resident's room to find them. She located the air boots on the floor in the closet and then placed them onto Resident #3's feet. She stated she looked in the chart and verified there was a physician's order to place air boots on the resident's right foot while in bed. She stated she had done the wound care earlier and had offloaded one foot one a pillow. LVN B stated even though Resident #3's heel was floated on a pillow; she still should have had her air boots on because there was an order to wear them to prevent skin breakdown. She said the air boots helped keep Resident #3's heel lifted off the mattress and have no pressure placed on it. LVN B said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 5 of 7 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 08/06/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's heel was not mushy, it was drying out. LVN B stated a mushy heel was a concern in that it could turn into a wound quickly in a couple hours if there was pressure on it. LVN B stated even with the use of Betadine to dry the heel out, if it was left on the mattress or pillow, then skin would start to go backwards in healing and get soft again. An observation of Resident #3 on 08/06/25 at 12:00 PM, (after investigator intervention) revealed she had two air boots one on her right and left feet. An interview with Resident #3's family member on 08/06/25 at 12:00 PM, revealed the resident got the wound on her right heel because she had neuropathy and was rubbing her heel skin on the mattress most likely because it felt good to itch it. The family member stated the wound did not appear to be getting better because the resident would indicate through grimacing at time during visits that it was hurting. The family member stated the air boots that were presently on Resident #3's feet she had never seen before and noted the roommate [Resident #4] was currently wearing the heel protectors she was used to Resident #3 wearing. She did not know why those were now being used for her roommate. 3. Record review of Resident #4's Face Sheet dated 08/06/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included acute osteomyelitis- left ankle and foot (a bone infection, usually bacterial, that develops over a short period, often within two weeks), pain, peripheral vascular disease (a circulation disorder that affects blood vessels outside of the heart and brain), muscle wasting and atrophy (loss of muscle mass and strength), methicillin resistant staphylococcus aureus infection (a type of staph that can be resistant to several antibiotic), diabetes mellitus (a chronic condition where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), neuropathic arthropathy (a condition where a joint breaks down due to nerve damage) and dementia (a decline in mental ability severe enough to interfere with daily life).Record review of Resident #4's admission MDS dated [DATE] reflected a BIMS score of 03, which indicated severe cognitive impairment. She had no signs or symptoms of psychosis, delirium, or rejection of care. Resident #4 had range of motion limitations on both sides of her lower extremities. Resident #4 was dependent on staff for all transfers and needed substantial/maximal assistance for bed mobility. Resident #4 was at risk of developing pressure ulcers/injuries and had one Stage 2 pressure ulcers that was present upon admission. She also had other ulcers, wounds and skin problems which included an infection of the foot. Resident #4 required pressure ulcer/injury care, applications of ointments/medications other than to feet and application of dressings to feet (with or without topical medications).Record review of Resident #4's care plan dated 07/15/25 reflected, [Resident #4] has a surgical incision s/p I&D to left plantar surface. Interventions did not include a discussion of offloading her feet/legs. Record review of Resident #4's physician wound care orders reflected, 1) Left plantar: Cleanse with NS, Pat dry, Apply calcium alginate with silver to wound bed cover with dry dressing daily (start date 07/25/2025-open ended), 2) Elevate/Float Heels while in bed Every Shift (start date 07/28/2025-open ended).Record review of Resident #4's initial H&P completed by the attending physician on 07/15/25, reflected, Patient on IV antibiotic for underlying left foot osteomyelitis with MRSA positive. An observation and interview of Resident #4 on 08/05/25 at 10:51 AM, revealed she said her left foot was where the wound was. The wound was observed to be wrapped and under a sock and her foot was not offloaded from the bed. Resident #4 stated she was not in any pain and did not know how the wound on her foot occurred. Her ability to articulate her thoughts was limited due to cognition. An interview with CNA C on 08/05/25 at 2:06 PM, revealed she was the CNA for Resident #3 and Resident #4 and they had just moved to the hall about a week prior. She stated both residents had wounds on their feet and their heels should be offloaded as a result. She stated she did not know about any air boots that were used for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676388 If continuation sheet Page 6 of 7 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 08/06/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #3. An interview with the wound care nurse (WC LVN D) on 08/06/25 at 1:15 PM, revealed she felt all residents' feet should be offloaded when they were in bed. She stated heel protectors such as air boots were used, Because we are trying to relieve pressure or residents' at risk for pressure, I want one on them because we don't want breakdown, pillows move when we offloaded, but it you put those boots on, they are not going anywhere. WC LVN D stated the charge nurses should be monitoring to ensure these interventions were in place and they were supposed to check it off on the MAR/TAR as being observed. WC LVN D stated, Therapy is notorious for not putting the air boots back on. An interview with LVN A on 08/06/25 at 1:45 PM, revealed air boots and heel protectors were important to reduce the friction a resident has with their skin on the bed. She stated if an offloading device was not in place and missing, the CNA should tell the charge nurse who would come and put it on. LVN A stated, however, that the nurses should be rounding too and should check to see that their assigned residents' feet were being offloaded. She stated if a resident's foot was not offloaded, they would develop a deep tissue injury on their heel, and that is when we get wounds, which we don't want.An interview with the DON on 08/06/25 at 2:20 PM, revealed monitoring for heel protectors such as air boots was the responsibility of the wound care nurse, and if the wound care nurse was not there, then it was to be done by the charge nurses.Review of the facility's policy titled, Wound Care Policies and Procedures-Pressure Ulcers in Adults revised 06/01/15 reflected, .5. Mechanical Loading and Support Surface Guideline.Use devices that relive or reduce pressure on the heels. Event ID: Facility ID: 676388 If continuation sheet Page 7 of 7