The Pavilion At Creekwood

Penalties

• Jan 5, 2025 — Fine ($14,901)
• Jan 5, 2025 — Fine ($14,901)
• Aug 27, 2024 — Fine ($9,872)

Inspection findings

1. Jun 1, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Jun 2, 2026 · CMS health inspection

2. Apr 14, 2026 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0009 Emergency Preparedness Deficiencies

     Include a process for Emergency Preparedness collaboration.

     Corrected May 7, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Apr 8, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0636 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.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

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

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0761 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.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 22, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 15, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected May 4, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 4, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 24, 2026 · CMS fire safety

3. Aug 6, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Aug 7, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Aug 7, 2025 · CMS health inspection

4. Feb 26, 2025 Health · 7 findings
   • Not serious Scope/severity D

     F0585 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.

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0655 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

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

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

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Feb 27, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Feb 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 27, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 17, 2025 · CMS fire safety

5. Jan 5, 2025 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jan 6, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Jan 6, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0742 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.

     Corrected Jan 6, 2025 · CMS health inspection

6. Aug 27, 2024 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0578 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.

     Corrected Aug 28, 2024 · CMS health inspection

7. May 20, 2024 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected May 21, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0757 Pharmacy Service Deficiencies

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

     Corrected May 21, 2024 · CMS health inspection

8. Jan 25, 2024 Health · 4 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jan 27, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jan 27, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Feb 26, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Feb 26, 2024 · CMS fire safety

9. Dec 12, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Dec 13, 2023 · CMS health inspection

10. Nov 21, 2023 Health · 2 findings
    • Not serious Scope/severity E Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 18, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0919 Environmental Deficiencies

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

      Corrected Nov 22, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• LEBLANC, RYAN — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• LEBLANC, RYAN — corporate officer, NOT APPLICABLE, since 01/01/2022
• LEBLANC, RYAN — adp of the snf, NOT APPLICABLE, since 01/01/2022
• RIGSBY, CAMELIA — adp of the snf, NOT APPLICABLE, since 12/01/2016
• FUNDAMENTAL ADMINISTRATIVE SERVICES LLC — adp of the snf, NOT APPLICABLE, since 07/01/2007
• FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLC — adp of the snf, NOT APPLICABLE, since 07/01/2007
• THI OF TEXAS LLC — operational/managerial control, NOT APPLICABLE, since 06/21/2007