The Pavilion At Creekwood has received an F grade based on CMS data, with a score of 16/100 — placing it among the lowest-rated nursing facilities in Texas. Families considering this Mansfield facility should carefully review its inspection history and quality metrics.
With 3.18 total nurse hours per resident per day, The Pavilion At Creekwood falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.
Recent CMS inspections identified 22 deficiencies at The Pavilion At Creekwood, including 4 classified as serious — among the most concerning citation levels. The most notable finding involved: provide appropriate pressure ulcer care and prevent new ulcers from developing..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.18 | 3.8 | Below Average |
| Registered Nurses (RN) | 0.42 | 0.7 | Below Average |
| Licensed Practical Nurses (LPN) | 0.93 | 0.7 | Above Average |
| Certified Nursing Assistants (CNA) | 1.83 | 2.4 | Below Average |
| Weekend Total Nursing | 2.76 | 3.8 | Below Average |
| Weekend RN Hours | 0.60 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0686 Severity EProvide appropriate pressure ulcer care and prevent new ulcers from developing.Aug 5, 2025 · Quality of Life and Care Deficiencies
- Tag 0684 Severity DProvide appropriate treatment and care according to orders, resident’s preferences and goals.Aug 5, 2025 · Quality of Life and Care Deficiencies
- Tag 0759 Severity EEnsure medication error rates are not 5 percent or greater.Feb 25, 2025 · Pharmacy Service Deficiencies
- Tag 0585 Severity DHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt eFeb 25, 2025 · Resident Rights Deficiencies
- Tag 0655 Severity DCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedFeb 25, 2025 · Resident Assessment and Care Planning Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 5.7% | 4.5% | Worse |
| Falls with major injury | 1.9% | 3.0% | Better |
| On antipsychotic medication | 3.8% | 14.5% | Better |
| Urinary tract infections | 0.0% | 2.5% | Better |
| ADL decline (daily activities) | 12.7% | 14.0% | Average |
| Excessive weight loss | 0.9% | 7.5% | Better |
| New/worsened incontinence | 20.4% | 45.0% | Better |
⚠️ Penalties & Fines
3 penalties recorded by CMS
Total fines: $39,674
How This Grade Was Calculated
This facility's grade of F is based on a score of 16 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 1★ → 8 pts (max 40)
- Health Inspection Rating: 2★ → 10 pts (max 25)
- Staffing Rating: 1★ → 4 pts (max 20)
- Quality Measures Rating: 4★ → 12 pts (max 15)
- Penalty deductions: -15 pts
- Fine deductions: -3 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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