Turtle Creek Rehabilitation and Wellness Center

In the surveyor’s words

From the most serious findings on record at Turtle Creek Rehabilitation and Wellness Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Feb 9, 2026

  Based on review of facility incident 2735892, documentation review, medical record review, interview, and observation, it was determined the facility failed to have an effective system in place to prevent residents from smoking in their room. The failure to monitor residents with recent behaviors of smoking in their rooms resulted in a fire in a resident's room that placed other residents at risk and caused other residents to be relocated in the facility. This deficient practice was evident for 3 (Residents #1, #2, #3) of 35 smokers in the facility and had the potential to affect all residents that resided at the facility.As a result of these findings an Immediate Jeopardy was called on 2/6/26 at 1:59 PM. The facility submitted a plan to remove the Immediacy on 2/6/26 at 5:23 PM. […]

• Actual harm, isolatedF600Oct 2, 2024

  Based on review of a facility reported incident, medical record review, facility documentation review, and staff interviews, it was determined the facility failed to honor a resident's wishes to not change position which resulted in a staff member pulling a resident's contracted fingers which resulted in a fractured finger. The failure to honor a resident's wishes while assisting in bed mobility resulted in actual harm to Resident #2. This was evident for 1 (#2) of 20 residents reviewed for facility reported incidents. […]

• No harm, potential for more than minimal, widespreadF880Apr 22, 2026

  Based on observation, interview, and record review, it was determined that the facility failed to 1) ensure that Personal Protective Equipment (PPE) was available for staff to provide Enhanced Barrier Precautions (EBP), and 2) ensure the clean area of the laundry room, including clean linens and laundry staff, were protected from exposure to wastewater from the washing machines. This was evident 1) for two (Residents #9 and #73) of 2 residents reviewed for EBP, and 2) during an observation of the laundry room, and this deficient practice had the potential to affect all residents.The findings include:1). […]

• No harm, potential for more than minimal, widespreadF850Oct 2, 2024

  Based on written and verbal complaints, documentation review and staff interview, it was determined the facility failed to obtain a full-time social worker when the certified number of beds exceeded 120 in the facility. Currently the facility was licensed for 140 certified beds. This was evident for 1 out of 1 required personnel and had the potential to affect all residents. The findings include: On 9/24/24 at 1:44 PM a review of complaint MD00209234 revealed Resident #4's responsible party (RP) complained that communication from the social work department dropped off in early 2024 after the social worker left and issues that the RP had pertaining to Resident #4's care went unanswered. On 9/25/24 at 12:33 PM an interview with Resident #4's RP was conducted. […]

• No harm, potential for more than minimal, patternF584Feb 27, 2025

  Based on record review, observation and interview, the facility failed to provide residents with an adequate supply of linens. This has the potential to affect all residents residing in the facility. The findings include: During a review of Intake #MD00164452 on 2/19/25 at 08:30 AM the complainant stated that the facility did not have enough towels and washcloths. On 2/20/25 at 09:30 AM, 2/20/25 at 12:30 PM and 2/21/25 at 8:00 AM, the surveyors observed that the linen carts in the hall contained only one or two towels and washcloths in the cart. During those observations Geriatric Nursing Assistants #7, #11, #12 and #13 were interviewed about the amount of linen they have to provide for resident care. […]