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The Pavilion At Creekwood

πŸ“ 2100 Cannon Dr, Mansfield, TX 76063 πŸ“ž (817) 779-6500 πŸ›οΈ 126 beds

Inspection History Overview

Detailed Inspection Reports

Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.

January 5, 2025 Complaint Investigation

Fines and Penalties by Year

2025 1 penalties totaling $29,803

$29,803
Jan 5, 2025

Fine

2022 3 penalties totaling $24,750

$15,000
Nov 30, 2022

Fine

$9,750
Nov 30, 2022

Fine

$15,000
Oct 3, 2022

Fine

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Health Violations by Year

2025 7 violations

Tag 0585 D Feb 26, 2025

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.

βœ“ Corrected: Feb 27, 2025
Tag 0655 D Feb 26, 2025

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

βœ“ Corrected: Feb 27, 2025
Tag 0755 D Feb 26, 2025

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

βœ“ Corrected: Feb 27, 2025
Tag 0759 E Feb 26, 2025

Ensure medication error rates are not 5 percent or greater.

βœ“ Corrected: Feb 27, 2025
Tag 0684 J Jan 5, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

βœ“ Corrected: Jan 6, 2025
Tag 0689 J Jan 5, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

βœ“ Corrected: Jan 6, 2025
Tag 0742 J Jan 5, 2025

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.

βœ“ Corrected: Jan 6, 2025

2024 4 violations

Tag 0755 E May 20, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

βœ“ Corrected: May 21, 2024
Tag 0757 D May 20, 2024

Ensure each resident’s drug regimen must be free from unnecessary drugs.

βœ“ Corrected: May 21, 2024
Tag 0558 D Jan 25, 2024

Reasonably accommodate the needs and preferences of each resident.

βœ“ Corrected: Jan 27, 2024
Tag 0812 F Jan 25, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

βœ“ Corrected: Jan 27, 2024
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2023 6 violations

Tag 0695 D Dec 12, 2023

Provide safe and appropriate respiratory care for a resident when needed.

βœ“ Corrected: Dec 13, 2023
Tag 0880 E Nov 21, 2023

Provide and implement an infection prevention and control program.

Tag 0919 D Nov 21, 2023

Make sure that a working call system is available in each resident's bathroom and bathing area.

βœ“ Corrected: Nov 22, 2023
Tag 0761 D Mar 21, 2023

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.

Tag 0580 D Feb 16, 2023

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Tag 0686 E Feb 16, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2022 11 violations

Tag 0558 D Nov 30, 2022

Reasonably accommodate the needs and preferences of each resident.

βœ“ Corrected: Dec 1, 2022
Tag 0656 D Nov 30, 2022

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

βœ“ Corrected: Dec 6, 2022
Tag 0730 E Nov 30, 2022

Observe each nurse aide's job performance and give regular training.

βœ“ Corrected: Dec 19, 2022
Tag 0880 E Nov 30, 2022

Provide and implement an infection prevention and control program.

βœ“ Corrected: Dec 28, 2022
Tag 0677 D Oct 3, 2022

Provide care and assistance to perform activities of daily living for any resident who is unable.

Tag 0812 F Oct 3, 2022

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Tag 0880 D Oct 3, 2022

Provide and implement an infection prevention and control program.

Tag 0684 D Jun 28, 2022

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

βœ“ Corrected: Jun 30, 2022
Tag 0777 D Jun 28, 2022

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

βœ“ Corrected: Jun 30, 2022
Tag 0558 D Apr 29, 2022

Reasonably accommodate the needs and preferences of each resident.

βœ“ Corrected: May 2, 2022
Tag 0690 D Jan 18, 2022

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

βœ“ Corrected: Jan 21, 2022
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2021 1 violations

Tag 0880 D Dec 21, 2021

Provide and implement an infection prevention and control program.

βœ“ Corrected: Jan 20, 2022

2020 1 violations

Tag 0695 D Oct 19, 2020

Provide safe and appropriate respiratory care for a resident when needed.

βœ“ Corrected: Oct 23, 2020
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2019 2 violations

Tag 0812 F Sep 19, 2019

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

βœ“ Corrected: Oct 15, 2019
Tag 0880 D Sep 19, 2019

Provide and implement an infection prevention and control program.

βœ“ Corrected: Oct 15, 2019

2018 5 violations

Tag 0690 D Aug 24, 2018

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

βœ“ Corrected: Sep 21, 2018
Tag 0755 E Aug 24, 2018

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

βœ“ Corrected: Sep 21, 2018
Tag 0758 E Aug 24, 2018

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

βœ“ Corrected: Sep 21, 2018
Tag 0805 D Aug 24, 2018

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

βœ“ Corrected: Sep 21, 2018
Tag 0880 D Aug 24, 2018

Provide and implement an infection prevention and control program.

βœ“ Corrected: Sep 21, 2018
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2017 2 violations

Tag 0371 F Jul 13, 2017

Store, cook, and serve food in a safe and clean way.

βœ“ Corrected: Jul 14, 2017
Tag 0469 F Jul 13, 2017

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

βœ“ Corrected: Jul 14, 2017
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