The Pavilion at Creekwood
2100 Cannon Dr, Mansfield, TX 76063 · Tarrant County · 126 certified beds · avg 97 residents/day · certified since Aug 3, 2015
Part of chain: FUNDAMENTAL HEALTHCARE (66 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 5, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 6, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 5, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 6, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 5, 2025 · F-0742 · triggered by a complaint
The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Why it matters: Residents with mental health needs who go untreated can suffer worsening symptoms, distress, and isolation.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 6, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 27, 2024 · F-0578 · triggered by a complaint
The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 28, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 1, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Aug 6, 2025 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 26, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 26, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Feb 26, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 26, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| Aug 27, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| May 20, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Jan 25, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Dec 12, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Nov 21, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 21, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | E |
| 2024 | 5 | 1 | J ▲ |
| 2025 | 9 | 3 | J ▲ |
| 2026 | 8 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $39,674.
| Date | Type | Amount / length |
|---|---|---|
| Jan 5, 2025 | Fine | $14,901 |
| Jan 5, 2025 | Fine | $14,901 |
| Aug 27, 2024 | Fine | $9,872 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.10 | 3.46 | 3.95 | bottom 31% in Texas; bottom 17% in the U.S. |
| Registered Nurse hours | 0.36 | 0.44 | 0.69 | bottom 44% in Texas; bottom 17% in the U.S. |
| Weekend total nurse staffing | 2.71 | 3.04 | 3.50 | bottom 31% in Texas; bottom 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.51 | 0.34 | 0.48 | top 12% in Texas; top 32% in the U.S. |
| Total nursing staff turnover (%) | 47.0 | 55.3 | 45.8 | top 38% in Texas; bottom 44% in the U.S. |
| RN turnover (%) | 35.7 | 54.6 | 42.9 | top 25% in Texas; top 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.21, RN 0.38, weekend 2.81. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | 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 | Corporate Officer | NOT APPLICABLE | 01/01/2022 |
| Leblanc, Ryan | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2022 |
| Leblanc, Ryan | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Rigsby, Camelia | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2016 |
| Thi of Texas LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/21/2007 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Mansfield | 1.7 mi | Mansfield, TX | ★★★★☆ | 3/5 | |
| Mansfield Medical Lodge | 2.1 mi | Mansfield, TX | ★★★★☆ | 4/5 | |
| Matlock Place Health & Rehabilitation Center | 3.8 mi | Arlington, TX | ★☆☆☆☆ | 1/5 | abuse |
| Arbrook Plaza | 7.5 mi | Arlington, TX | ★★★☆☆ | 3/5 | |
| Town Hall Estates - Arlington, INC. | 8.0 mi | Arlington, TX | ★★☆☆☆ | 1/5 | |
| Avir at Kennedale | 8.4 mi | Kennedale, TX | ★☆☆☆☆ | 2/5 | |
| Crestview Court | 9.0 mi | Cedar Hill, TX | ★★★★★ | 4/5 | |
| Cedar Hill Healthcare Center | 9.1 mi | Cedar Hill, TX | ★★☆☆☆ | 3/5 | |
| Midlothian Healthcare Center | 9.5 mi | Midlothian, TX | ★★★☆☆ | 3/5 | |
| Midtowne Meadows Health & Rehab | 9.5 mi | Midlothian, TX | ★★★★☆ | 5/5 | |
| Green Oaks Nursing & Rehabilitation | 9.9 mi | Arlington, TX | ★★★☆☆ | 2/5 | |
| Avir at Arlington | 12.0 mi | Arlington, TX | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676388.