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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Pavilion at Creekwood boasts an advanced care plan leading to a speedy recovery. The skilled nursing and rehabilitation home aims to enhance the quality of life for its residents by ensuring that seniors can satisfy their holistic wellness. The resident-centered community has a warm and welcoming atmosphere that many seniors have praised because it helps them feel comfortable and have a sense of belonging.
The Pavilion uplifts the standard of senior recovery with its services delivered by a dedicated team of caregivers who strive to meet and follow a resident’s individualized care plan for a complete healing period. Areas of expertise include wound care, pain management, palliative care, cardiac rehabilitation, and physical, occupational, and speech therapy.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 231st out of 289 homes in Texas. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 25m per day | ▼ 4% State avg: 26m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 56m per day | ■ Avg State avg: 57m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 1h 50m per day | ▼ 9% State avg: 2h 1m per day · National avg: 2h 21m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 2h 47m per day | ▼ 6% State avg: 2h 59m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 1m per day | ▼ 75% State avg: 4m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 36m per day | ▲ 71% State avg: 21m per day · National avg: 29m per day |
Lower than the Texas average: 63.5%The Pavilion at Creekwood is administrated by Ryan K Leblanc.
Key information about the people who lead and staff this community.
In Texas, the Health and Human Services Commission (HHSC) is the primary regulatory body that conducts unannounced inspections and publishes quality reports for all long-term care homes.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Texas state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Citations
| This Facility | TX Average | vs. TX Avg |
|---|---|---|---|
|
Total citations
Formal regulatory issues recorded by inspectors across all inspection types.
| 5 | 6 | This facility has 17% fewer total citations than a typical Texas nursing home (5 vs. TX avg 6).↓ 17% better |
|
Health citations
Violations related to resident care, clinical practices, and day-to-day operations.
| 1 | 2 | This facility has 50% fewer health citations than a typical Texas nursing home (1 vs. TX avg 2).↓ 50% better |
|
Life safety citations
Violations related to building safety — fire prevention, emergency egress, and similar.
| 4 | 6 | This facility has 33% fewer life safety citations than a typical Texas nursing home (4 vs. TX avg 6).↓ 33% better |
|
Citations per year
Average citations per year since 2022.
| 1.3 | 1.5 | This facility has 13% fewer citations per year than a typical Texas nursing home (1.3 vs. TX avg 1.5).↓ 13% better |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspection on August 6, 2025, identified deficiencies related to wound care and pressure ulcer management for several residents. Earlier inspections showed a pattern of issues involving resident care, medication management, and infection control, including substantiated complaints about medication errors, failure to honor a DNR order, and inconsistent respiratory care. Inspectors cited problems with grievance resolution, baseline care planning, pharmaceutical services, and sanitary conditions in linen closets, as well as call light system functionality. Complaint investigations were substantiated in multiple cases, including one involving an Immediate Jeopardy that was resolved with corrective actions and staff re-education. The facility’s inspection history shows ongoing challenges with clinical care and documentation, with some corrective efforts noted but deficiencies persisting over time.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsTexas average 7.4
Last Health inspection on Aug 2025
Texas average 25.9
Texas average 3.67
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
10 of 24 citations resulted from standard inspections; and 14 of 24 resulted from complaint investigations.
100% worse than Texas averageTexas average: 2
100% better than Texas averageTexas average: 0.4
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
0% compared with Texas average
0% compared with Texas average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.4 hoursThis role is partially covered by contractors.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hoursThis role is partially covered by contractors.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.8 hoursThis role is partially covered by contractors.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
4,869 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 38 | 15 | 53 | 13,387 | 92 | 100% | 7.8 |
| Licensed Practical Nurse | 21 | 15 | 36 | 6,121 | 92 | 100% | 7.6 |
| Medication Aide/Technician | 10 | 0 | 10 | 2,865 | 92 | 100% | 9.4 |
| Registered Nurse | 13 | 2 | 15 | 2,630 | 89 | 97% | 8.4 |
| Speech Language Pathologist | 0 | 8 | 8 | 1,799 | 81 | 88% | 7.4 |
| Physical Therapy Aide | 0 | 9 | 9 | 1,571 | 81 | 88% | 7.3 |
| RN Director of Nursing | 4 | 0 | 4 | 1,454 | 77 | 84% | 7.8 |
| Dietitian | 1 | 0 | 1 | 526 | 66 | 72% | 8 |
| Physical Therapy Assistant | 0 | 5 | 5 | 525 | 66 | 72% | 7.7 |
| Mental Health Service Worker | 1 | 0 | 1 | 514 | 64 | 70% | 8 |
| Dental Services Staff | 1 | 0 | 1 | 512 | 59 | 64% | 8.7 |
| Administrator | 1 | 0 | 1 | 432 | 54 | 59% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 424 | 53 | 58% | 8 |
| Qualified Social Worker | 0 | 6 | 6 | 255 | 56 | 61% | 4.2 |
| Respiratory Therapy Technician | 0 | 4 | 4 | 206 | 75 | 82% | 2.6 |
| Occupational Therapy Aide | 1 | 0 | 1 | 200 | 25 | 27% | 8 |
| Clinical Nurse Specialist | 1 | 0 | 1 | 131 | 16 | 17% | 8.2 |
| Occupational Therapy Assistant | 0 | 2 | 2 | 67 | 10 | 11% | 6.7 |
| Qualified Activities Professional | 1 | 0 | 1 | 3 | 1 | 1% | 3 |
Includes penalties issued in 2024-2025
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
51% lower than Texas averageTexas average: $80K
21% more fines than Texas averageTexas average: 2.5
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
0
100% fewer payment denials than Texas averageTexas average: 0.2
Penalties are imposed by CMS for violations of federal nursing home regulations.
3 penalties in the past 3 years
Multiple penalties were reported in the last 3 years.
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Jan 5, 2025
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Jan 5, 2025
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Aug 27, 2024Last updated: Jan 2026
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
6.0
31% better than Texas averageTexas average: 8.6
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
12.7
21% better than Texas averageTexas average: 16.0
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
7.3%
55% better than Texas averageTexas average: 16.2%
Percent of long-stay residents whose ability to move independently worsened
13.3%
18% better than Texas averageTexas average: 16.2%
Percent of low risk long-stay residents who lose control of their bowels or bladder
17.4%
11% worse than Texas averageTexas average: 15.7%
Percent of long-stay residents experiencing one or more falls with major injury
1.2%
64% better than Texas averageTexas average: 3.2%
Percent of long-stay high risk residents with pressure ulcers
6.6%
48% worse than Texas averageTexas average: 4.4%
Percent of long-stay residents with a urinary tract infection
0.0%
100% better than Texas averageTexas average: 0.8%
Percent of long-stay residents who lose too much weight
1.5%
58% better than Texas averageTexas average: 3.5%
Percent of long-stay residents who have depressive symptoms
1.2%
57% better than Texas averageTexas average: 2.9%
Percent of long-stay residents who received an antipsychotic medication
2.5%
69% better than Texas averageTexas average: 7.9%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
99.2%
In line with Texas averageTexas average: 97.3%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
97.2%
In line with Texas averageTexas average: 97.9%
Number of hospitalizations per 1,000 long-stay resident days.
2.30
8% worse than Texas averageTexas average: 2.13
Number of outpatient emergency department visits per 1,000 long-stay resident days.
1.94
6% better than Texas averageTexas average: 2.07
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
98.8%
9% better than Texas averageTexas average: 90.4%
Percent of short-stay residents who newly received an antipsychotic medication
0.5%
63% better than Texas averageTexas average: 1.4%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
98.9%
12% better than Texas averageTexas average: 88.0%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
24.6%
5% better than Texas averageTexas average: 25.9%
Percentage of short-stay residents who had an outpatient emergency department visit.
12.3%
In line with Texas averageTexas average: 12.0%
Percentage of SNF residents who experience falls with major injury during their stay.
1.6%
103% worse than Texas averageTexas average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
71.3%
33% better than Texas averageTexas average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
66.7%
32% better than Texas averageTexas average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
23% of new residents, usually for short-term rehab.
75% of new residents, often for short stays.
2% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
106Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for The Pavilion at Creekwood based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #106 / 297Payroll — State benchmarkedThis home is ranked 106th out of 297 homes in Texas. Shows total annual staff payroll benchmarked to the Texas average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Residents typically stay for brief periods, with frequent admissions and discharges throughout the year.
2.5 miles from city center
Estimated distance in miles from Mansfield's city center to The Pavilion at Creekwood's address, calculated via Google Maps.
— 0.63 miles to nearest hospital (Methodist Mansfield Medical Center)
Add your location
The Pavilion at Creekwood is located in Mansfield, Texas.
Here are the financial assistance programs available to residents in Texas.
The information below is reported by the Texas Health and Human Services Commission.
| Mansfield Nursing and Rehabilitation |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Mansfield | 72 | 45.6% | -28% | 3.27 | +67% | -10% | $0 | 4 | 1.3 | - | 39 | 60 | San Saba I Enterprises, LLC | $3.6M | $2.0M | 54.9% | 676399 | ||||
| Mansfield Medical Lodge |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Mansfield (Polo Crossing) | 118 | 81.2% | +28% | 2.88 | -35% | -21% | $6.0k | 14 | 2.3 | 2 | 94 | 39 | - | $13.3M | $4.9M | 37% | 676143 | ||||
| The Pavilion at Creekwood |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Mansfield (Monticello) | 126 | 55.6% | -12% | 3.12 | +23% | -14% | $49.4k | 24 | 2.2 | 4 | 70 | 34 | Ryan Leblanc | $16.0M | $5.8M | 36.3% | 676388 |
The Pavilion at Creekwood is in the Monticello neighborhood of Mansfield.
The legal owner and operator of The Pavilion at Creekwood is Mansfield Long Term Care, LLC.
The Pavilion at Creekwood has a walk score of 34. Somewhat walkable. A few nearby services may be reachable on foot, but most trips require transportation.
According to TX state health department records, The Pavilion at Creekwood's license number is 145851.
According to TX state health department records, The Pavilion at Creekwood's license expires on March 8, 2028.
The Pavilion at Creekwood's occupancy is 56%.
Ryan K Leblanc is the administrator of The Pavilion at Creekwood.
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