2100 Cannon Dr, Mansfield, TX 76063 · Tarrant County · (817) 779-6500
126 certified beds, about 97 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2015
CMS Care Compare ratings, data as of September 1, 2026 · CCN 676388 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 14, 2026, inspectors cited 7 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 25 health citations since November 2023, 4 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 3 fines totaling $39,674 in the last three years; the largest was $14,901, and the latest is dated January 5, 2025.
Nurses and nurse aides worked 3.21 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.38 of those hours.
47.0% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to Fundamental Healthcare, an affiliated group of 66 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 25 health citations on file.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of five residents (Resident #1) reviewed for quality of life. CNA A and CNA B failed to transfer Resident #1 in accordance with the facility's policy when they failed to ensure her right wheelchair brake was locked and secured prior to completing a mechanical lift transfer. This failure could place residents at risk for accidents/injuries, including falls.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of records of receipt and dispositon of all controlled drugs in sufficient detail to enable an accurate reconciliation for 3 of (200 hall, 300 hall, and 400 hall) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident #60's Tylenol#3-300 mg (controlled medication) by taping a narcotic medication and storing it in medication cart. The facility failed to ensure proper storage and disposal of Resident #68's hydrocodone 5-325mg (controlled medication) by taping a narcotic medication and storing it in medication cart. The facility failed to ensure proper disposal Resident #120's lorazepam 0.5mg (controlled medication) Resident discharged [DATE]. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and disposal of for 3 (hall 300, 400 hall, and 200 hall) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure Resident #47's Trelegy elipta (a disposable, dry-powder inhaler) was dated after opening and before storage in the medication cart. The facility failed to ensure Resident #90's Breo elipta (in haler used to treat asthma) was dated after opening and before storage in the medication cart The facility failed to ensure of Resident #58's unopened Lantus SoloStar (disposable, prefilled, long-acting insulin) which required refrigeration per manufacturer's guidelines was observed stored unrefrigerated. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: There was a box of dinner rolls that was opened and unsealed in the walk-in deep freezer. There was a bag of lettuce heads that was opened, unsealed, without a label and use-by date in the walk-in refrigerator. There was a bag of mixed salad greens that had been previously opened and partially used, wrapped in clear plastic wrapping without a label and use-by date in the walk-in refrigerator. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.
Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #79) reviewed for resident rights. The facility did not ensure LVN A knocked on the door before entering Resident #79's room or announced herself. These failures could place residents at an increased risk of diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #79 and Resident #28) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #79 and #28's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
Inspectors wroteBased on interview and record review, the facility failed to conduct a Comprehensive Assessment within 14 calendar days after admission, as well as at least once every 12 months, for one (Resident #28) of five residents reviewed for Comprehensive Assessments and timing. The facility failed to ensure a Comprehensive MDS Assessment for Resident #28 was completed within 14 days after her admission to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.
Inspectors wroteBased on interview and record review the facility failed to ensure residents was free of any significant medication error of 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure accurate transcription of Resident #1's prednisone orders (medication used to reduce inflammation and suppress the immune system, and severe illness flare-ups resulting in a missed medication dose. The failure resulted in a medication error and placed the resident at risk for adverse clinical outcomes, worsening the resident's condition or potential harm due to omission of the prescribed medication.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents with pressure ulcers and at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #2, #3 and #4) of six residents reviewed for treatment/services for pressure ulcers.1. The facility failed to ensure pressure was offloaded from Resident #2's unstageable deep tissue injury on his left heel on 08/05/25. 2. The facility failed to ensure Resident #3's right heel air boot was in place to relieve and reduce pressure to a healing wound on 08/05/25.3. The facility failed to ensure pressure was offloaded on Resident #4's healing surgical incision site on her lower leg on 08/05/25. [...]
Inspectors wroteBased on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Residents #1) of five residents reviewed for quality of care. The facility failed to apply a dressing to cover Resident #1's recently infected wound (non-pressure related) on her left foot, when she was observed with it exposed to air on 08/05/25. |This failure could place residents with wounds at risk of a decline in their healing progression as well as at risk for infection and discomfort.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 45 medication administration opportunities with 11 errors resulting in a 24% medication error rate, for 2 of 6 residents (Residents #52 and #65) reviewed for medication administration. 1. The facility failed to ensure MA A administered a medication as ordered to Resident #52 by crushing Nifedipine ER (used to treat hypertension (high blood pressure) and angina (chest pain)); a medication that should not be crushed. 2. The facility failed to ensure MA B administered Resident #65 medication per physician orders, medications scheduled at 7 am were administered at 11:18 am This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.
Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances residents had and ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for one (Resident #99) of five residents reviewed for grievances. The facility failed to document any attempts to resolve Resident #99's grievance when she expressed concern that CNA G refused to provide incontinent care. [...]
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #99) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #99. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.
Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #99) of 40 resident reviewed for pharmacy services. The facility failed to ensure the 400 Hall nurses' medication cart had an accurate narcotic count for Resident #99. This failure could place residents at risk for medication errors, drug diversion, and delays in medication administration.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #2) of 3 residents reviewed for quality of care. RN C failed to assess and notify the physician when Resident #2 fell in the bathroom on 10/05/24. The resident required hospitalization and suffered a clavicle fracture. On 01/03/25 at 1:40 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents and injury for 1 of 3 residents (Resident #3) reviewed for accidents and supervision. CNA A and RN B failed to ensure that Resident #3 was not left alone in the shower chair in his room. As a result, Resident #3 fell out of the shower chair, obtaining a hematoma to his head and being sent to the hospital. On 01/03/25 at 5:00 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of, neglect, serious injury, and death.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that a resident who was diagnosed with a mental illness or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (Resident #1) of 5 residents reviewed for services for mental/psychosocial concerns, in that: LVN O failed to follow the facility's suicide policy when Resident #1 made an outcry of self-harm on 01/01/25. An IJ was identified on 01/03/25. The IJ template was provided to the facility on [DATE] at 5:09 PM. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of six residents reviewed for advanced directives, in that: The facility failed to honor the rights of Resident #1's wishes to die a dignified death by failing to honor a signed OOH DNR order on 8/21/2024 at 07:42 pm when LVN A failed to inform EMS of Resident #1's DNR status and a full code was initiated to include CPR for approximately 43 minutes when Resident #1 became unresponsive. An Immediate Jeopardy (IJ) was identified on 08/26/24 at 03:25 PM. The IJ template was provided to the facility on [DATE] at 03:41 PM and signed by the Administrator. [...]
Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for five (Residents #1, #2, #3, #4, and #5) of five residents reviewed for pharmacy services related to new admissions. 1. The facility failed to follow physician orders and provide Resident #1 with Clozapine, an antipsychotic medication to treat her schizoaffective disorder for two weeks (03/04/24 through 03/17/24). 2. The facility failed to follow physician orders, acquire, and administer Resident #2 with Buspirone, Gabapentin, Oxybutynin Chloride, Trazadone, Venlafaxine, and Hydroxyzine on 05/03/24, the day after she admitted to the facility. 3. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident's drug regimen must be free from unnecessary drugs, without adequate indications for its use for one (Resident #4) of three residents reviewed for psychotropic medications. The facility failed to ensure Resident #4 was prescribed Seroquel (quetiapine fumarate) without adequate indications for its use. The failure could affect residents by placing them at risk for possible adverse side effects, a decreased quality of life and continued use of possible unnecessary medications.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the refrigerator and freezer located in the kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 01/23/24 at 8:30 AM revealed: - 1 box of homestyle ring donuts open and exposed to air; and - 1 box of turkey bacon open and exposed to air. Observation of the facility's freezer storage on 01/23/24 at 9:37 AM revealed: -1 box of sweet yeast steakhouse roll dough open and exposed to air; - 1 cup of unidentified green colored food on the floor; and - a piece of clear tape on the floor. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of five residents (Resident #15) reviewed for reasonable accommodations. The facility failed to provide assistance to Resident #15 after answering her call light. This failure could place residents at risk of not being able to contact staff and their needs not being met.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needs respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 (Resident #1) of 4 residents reviewed for respiratory services. Facility staff failed to ensure Resident #1's CPAP (continuous positive airway machine used to keep airway open while sleeping) was offered and applied while she was sleeping or napping as ordered. This failure could place residents at risk of not having their respiratory needs met.
Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of four clean linen closets (100, 200, 300, 400 Halls) reviewed for infection control. The facility failed to ensure clean linen closets were kept sanitary. This failure could place residents at risk of cross-contamination resulting in infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for one of thirteen residents reviewed for (Resident #1) environment. The facility failed to ensure Resident #1 had a working call light. This failure could place residents at risk of not being able to get staff assistance when they needed it.
11 fire safety citations on file: 6 on April 14, 2026, 3 on February 26, 2025, 2 on January 25, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| January 5, 2025 | Fine | $14,901 |
| January 5, 2025 | Fine | $14,901 |
| August 27, 2024 | Fine | $9,872 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.21 | 3.39 | 3.86 |
| Registered nurses | 0.38 | 0.43 | 0.69 |
| All nursing staff on weekends | 2.81 | 2.98 | 3.42 |
| Nurse aides | 1.89 | ||
| Licensed practical nurses | 0.94 | ||
| Nursing staff turnover (share who left in a year) | 47.0% | 55.3% | 45.8% |
| Registered nurse turnover | 35.7% | 54.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.96 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.37 on weekdays and 2.81 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.15 in April to June 2025 to 3.21 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.21 | 0.38 | 3.37 | 2.81 | 2.0% | 0 of 90 | 97 |
| Oct to Dec 2025 | 3.13 | 0.37 | 3.24 | 2.84 | 1.7% | 0 of 92 | 94 |
| Jul to Sep 2025 | 3.18 | 0.42 | 3.34 | 2.76 | 0.6% | 0 of 92 | 100 |
| Apr to Jun 2025 | 3.15 | 0.30 | 3.30 | 2.79 | 1.0% | 0 of 91 | 95 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.2 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.6 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.1 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 32.1 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.5 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 4.2 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.4 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 10.8 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.8 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for The Pavilion at Creekwood's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (66.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
66.7% this home
Better than the national rate
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 189 eligible stays.
12.2% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 209 eligible stays.
8.6% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 124 eligible stays.
89.1% this home
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 64 residents counted.
2.2% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 92 residents counted.
0.9% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 92 residents counted.
98.0% this home
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 51 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: MANSFIELD LONG TERM CARE, LLC. CMS links this home to Fundamental Healthcare, a group of 66 nursing homes averaging 2.5 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Leblanc, Ryan | Corporate officer | Individual | 01/01/2022 | |
| Thi of Texas LLC | Operational/managerial control | Organization | 06/21/2007 | |
| Leblanc, Ryan | Operational/managerial control | Individual | 01/01/2022 | |
| Fundamental Administrative Services LLC | Adp of the SNF | Organization | 07/01/2007 | |
| Fundamental Clinical and Operational Services, LLC | Adp of the SNF | Organization | 07/01/2007 | |
| Leblanc, Ryan | Adp of the SNF | Individual | 01/01/2022 | |
| Rigsby, Camelia | Adp of the SNF | Individual | 12/01/2016 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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