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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 70 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 50% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. The latest standard survey recorded 10 findings, above the TX average of 9.1. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Families considering The Pavilion at Creekwood will find a stark divide between the highly praised rehabilitation and physical therapy teams and severe allegations of nursing neglect. While many reviewers laud the facility's cleanliness and the effectiveness of the therapy staff in post-surgery recovery, multiple families report critical issues regarding hygiene, unresponsive night staff, and inadequate medication management.
Quality Themes
Tap a score for detailsStrengths
Concerns
Rating Trends
Tap a year to see what changed
Distribution · 72 analyzed
The owner relies heavily on a small set of repetitive templates for positive reviews, often using identical phrasing for different users. While they attempt to address negative reviews with more specific language, the responses frequently revert to standardized corporate apologies and requests for offline communication.
Personalized based on this facility's data
Key Review Excerpts
“The facility is absolutely stunning! The leadership team is truly exceptional, showing genuine care for the residents and the wider community.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
13
measures
1
measures
3
measures
Residents whose walking got worse
Residents on antipsychotic medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents vaccinated for pneumonia
Residents whose bladder or bowel control got worse
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Families have filed multiple complaint reports leading to 12 deficiencies, indicating ongoing concerns about treatment and care, medication management, and safety measures. The facility shows recurring issues with appropriate treatment according to resident preferences, medication safety, and fire safety systems across multiple surveys from 2022 to 2025. While all violations have been corrected, the pattern of repeated problems in core care areas suggests families should carefully evaluate whether this facility can consistently meet their loved one's needs.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
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.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Federal Penalties
Fine
Jan 5, 2025
$14,901
Fine
Jan 5, 2025
$14,901
Fine
Aug 27, 2024
$9,872
Mansfield Long Term Care, LLC
for profit
RYAN K LEBLANC
Fundamental Healthcare
66 facilities nationwide
Chain avg rating: 2.8/5 · Rank 25 of 26 (Lowest rating)
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
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Google Reviews
70 reviews from families & visitors
Official Website
Visit pavilionatcreekwood.com
Medicare data downloads
Original nursing home datasets
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