The Pavilion at Creekwood

Certification

Medicare-certified.

Ratings

Inspection history (28)

Records from November 2022 to April 2026.

• April 14, 2026

  Tag F0755

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

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected April 15, 2026.

• April 14, 2026

  Tag F0812

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

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected April 15, 2026.

• April 14, 2026

  Tag F0760

  Ensure that residents are free from significant medication errors.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected April 15, 2026.

• April 14, 2026

  Tag F0550

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

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected April 15, 2026.

• April 14, 2026

  Tag F0636

  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected April 15, 2026.

• April 14, 2026

  Tag F0558

  Reasonably accommodate the needs and preferences of each resident.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected April 8, 2026.

• April 14, 2026

  Tag F0761

  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.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected April 15, 2026.

• August 6, 2025

  Tag F0684

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

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected August 7, 2025.

• August 6, 2025

  Tag F0686

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

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected August 7, 2025.

• February 26, 2025

  Tag F0655

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

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected February 27, 2025.

• February 26, 2025

  Tag F0585

  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.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected February 27, 2025.

• February 26, 2025

  Tag F0755

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

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected February 27, 2025.

• February 26, 2025

  Tag F0759

  Ensure medication error rates are not 5 percent or greater.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected February 27, 2025.

• January 5, 2025

  Tag F0689

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

  Severity J: isolated, immediate jeopardy. Corrected January 6, 2025.

• January 5, 2025

  Tag F0684

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

  Severity J: isolated, immediate jeopardy. Corrected January 6, 2025.

• January 5, 2025

  Tag F0742

  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.

  Severity J: isolated, immediate jeopardy. Corrected January 6, 2025.

• August 27, 2024

  Tag F0578

  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.

  Severity J: isolated, immediate jeopardy. Corrected August 28, 2024.

• May 20, 2024

  Tag F0757

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

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected May 21, 2024.

• May 20, 2024

  Tag F0755

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

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected May 21, 2024.

• January 25, 2024

  Tag F0558

  Reasonably accommodate the needs and preferences of each resident.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected January 27, 2024.

Penalties (3)

Total fines: $39,674

• January 5, 2025 · Fine

  CMS recorded a civil money penalty of $14,901 against this nursing home on January 5, 2025.

• January 5, 2025 · Fine

  CMS recorded a civil money penalty of $14,901 against this nursing home on January 5, 2025.

• August 27, 2024 · Fine

  CMS recorded a civil money penalty of $9,872 against this nursing home on August 27, 2024.

Staffing

3.19 nurse hours per resident per day in Q2 2026, up from 3.13 in Q4 2025.

From the payroll records nursing homes file with CMS.

Ownership

For profit

• Parent company: Fundamental Clinical and Operational Services, LLC