Turtle Creek Rehabilitation and Wellness Center

Inspectors wroteBased on record review and interviews, it was determined the facility staff failed to notify the practitioner when a resident was assessed to have extremely high blood glucose levels. This was evident for 1 (#2) of 2 residents reviewed for neglect.

Inspectors wroteBased on review of facility reported incident investigations and staff interview it was determined that the facility failed to thoroughly investigate allegations of neglect. This was evident for 1 (#4) of 2 residents for neglect.

Inspectors wroteBased 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.

Inspectors wroteBased on record reviews, observations, and interviews, it was determined that the facility failed to treat residents with respect and dignity during mealtime. This was evident in one of two dining observations during the recertification survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives when new orders for life-sustaining treatment were implemented. This was evident for 1 (Resident #58) out of 5 residents reviewed for advance directives.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the resident and the resident's representative were provided the written notice of transfer when the resident was transferred to the hospital. This was found to be evident for one (Resident #4) out of one resident reviewed for hospitalization.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed for 1 (Resident #59) of 1 Residents reviewed for PASARR.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed 1) failed to review and revise a resident's care plan, and 2) to ensure interdisciplinary care plan meetings were held to address residents' care needs after the completion of the Minimum Data Set assessment. This was found to be evident for 1) one resident (Resident #6) of five reviewed for advance directives, and 2) two residents (Resident #108 and #51) of four residents reviewed for neglect.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure physician-ordered medications were administered as prescribed, including the correct medication, dose, and timing, for 3 (Resident #3, Resident #38, and Resident #55) of 3 Residents observed during the medication administration observation. This deficient practice has the potential to affect all residents receiving medications on all nursing units.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to have an effective system in place to ensure residents only had one active Maryland Order for Life-Sustaining Treatment (MOLST). This was evident for 1 (Resident #6) of 5 residents reviewed for advanced directives.

Inspectors wroteBased on record reviews, interviews, and observations, it was determined that the facility failed to provide activities based on the resident's comprehensive assessment. This was evident for 1 (Resident #51) of 4 residents reviewed for neglect.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure lab tests that were required to determine if a specific medication needed to be administered were obtained. This was found to be evident for one (Resident #40) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure residents at risk for developing pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #45) of 4 residents reviewed for pressure injuries.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure urology appointments for monthly suprapubic catheter changes were scheduled in a timely manner. This was found to be evident for one (Resident #40) out of two residents reviewed for urinary catheter care.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to a resident requiring such services according to professional standards of practice. This was evident for 1 (Resident #6) of 2 residents reviewed for pain management.

Inspectors wroteBased on observation, record review, and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with physician orders and accepted standards of practice. This deficient practice resulted in a medication error rate of 17.24% (5 errors out of 29 opportunities), exceeding the allowable 5% error rate.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure complete and accurate hospice documentation was maintained and readily accessible for 1 (Resident #9) of 1 Residents reviewed for Hospice Care.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on review of facility documentation of employee education records and interview, it was determined that the facility failed to ensure all staff received mandatory Quality Assessment and Performance (QAPI) training (Staff #20). This was evident for 1 of 5 employees reviewed during a complaint survey.

Inspectors wroteBased on review of facility documentation of employee education records and interview, it was determined that the facility failed to ensure all staff received mandatory Compliance and Ethics training annually (Staff #20). This was evident for 1 of 5 employees reviewed during a complaint survey.

Inspectors wroteBased on review of facility documentation of employee education records and interview, it was determined the facility failed to ensure all nurse aides received 12 hours of training annually that included dementia management and abuse prevention (Staff #20). This was evident for 1 of 5 nurse aides reviewed during a complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to properly store food in accordance with professional standards for food service and safety. This was found evident in 1 of 3 kitchen observations and 2 out of 2 unit storage refrigerators during the survey. This has the potential to affect all residents.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide adequate privacy in resident bathrooms. This was found to be evident throughout the facility during the recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to recognize the rights of a Resident. This was found evident of 1 (Resident #56) of 46 residents reviewed during the survey.

Inspectors wroteBased on resident interview, medical record review, and staff interviews, it was determined that the facility failed to adjust the care plan to reflect the resident's preferences. This was evident for 1 (Resident #22) of 8 residents reviewed during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) order. This was found to be evident for 1 (Resident #24) out of 5 residents reviewed for MOLST orders and advance directives during an annual survey.

Inspectors wroteBased on observation, record review, review of facility's policy and interview, it was determined that the facility staff failed to document ongoing re-assessments that would help determine the necessity of restraints for a resident who utilized a restraint. This was evident for 1 (Resident #10) of 1 resident reviewed for restraints during the survey.

Inspectors wroteBased on the facility's investigation on report, staff record review, the facility's policy and procedures for abuse prevention, and facility staff interview, it was determined the facility failed to prevent further potential abuse during an active investigation of abuse. This was evident for 1 resident (#143) of 7 residents reviewed for abuse during the annual survey.

Inspectors wroteBased on record review, and interviews, it was determined the facility failed to notify the Ombudsman of resident's transfers. This was found evident of 3 (Resident #27, #4, & #40) of 6 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to code the resident's discharge status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #141) of 1 resident reviewed during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to prepare all relevant resident information incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's transfer request to another nursing facility. This was evident for 1 (Resident #54) out of 2 residents reviewed for timely safe discharge during an annual survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to provide treatments according to a Resident's plan of care. This was found evident of 2 (Resident #56, #51) out of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on review of staffing information, medical records and interviews, it was determined that the facility failed to ensure sufficient weekend staffing on each type of personnel on a 24-hour basis to provide nursing care and answering call lights. This was found to be evident weekends during the period of 12/29 to 2/1/25 of an annual survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for 1 (Resident #51) out 6 residents reviewed for medication regimen review.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to 1) act upon recommendations made by consulting the Pharmacist in a timely manner; and 2) the attending Physician failed to document that he reviewed and addressed the Pharmacist's identified irregularities in the resident's medical record. This was found evident of 2 (Resident #56 & #92) of 5 residents reviewed for unnecessary medication during the annual survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure a medication error rate of less than 5% during the medication administration observation. This was evident for 3 medication errors out of 25 opportunities which resulted in a medication error rate of 12%.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to: 1) properly store medications and 2) ensure medications were properly labeled with expiration date. This was evident for 2 of 3 medication carts observed during the annual survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain the outdoor garbage storage area in a manner to prevent the harboring pests.

Inspectors wroteBased on interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 1 (Resident #50) of 46 residents reviewed during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide maintenance services necessary to maintain a clean, comfortable, and homelike environment in the kitchen and resident rooms. This was found evident on: 1) one exterior door leading to the garbage disposal area, and 2) 2 resident rooms (#113 and #117) and one resident shower room during the recertification survey.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on complaint review, environmental observations, and interview, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 2 of 2 nursing units observed during a complaint survey.

Inspectors wroteBased on reviews of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 5 (#11, #6, #2, #20) of 22 facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents and responsible parties). This was evident for 7 (Resident #5, #9, #10, #17, #4, #1, #2) of 51 residents reviewed during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health This was evident for 5 (Resident #7, #8, #10, #24, #3) of 51 residents reviewed for quality of care during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #40). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to treat each resident in a dignified manner by pulling a resident down the hallway backwards. This was evident for 2 (#48, #4) residents observed during random observations on 2 of 3 nursing units during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to notify a resident's physician for a change in status (Resident #10). This was evident for 1 of 51 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident and resident representative within 48 hours of admission to the facility (Resident #40). This was evident for 1 of 3 residents reviewed for baseline care plans during a complaint survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to ensure a resident's plans of care included individual resident care needs and interventions to assist each resident in reaching their highest practicable level of wellbeing. This was evident for 1 (#24) of 51 residents reviewed during a complaint survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on complaint, medical record review and staff interview it was determined the facility failed to develop an individualized discharge plan and update a discharge care plan for a resident admitted to the facility for rehabilitation. This was evident for 1 (#1) of 27 residents reviewed for complaints.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that colostomy care was provided to a resident with a colostomy. This was evident for 1 (16) of 1 resident reviewed with a colostomy.

Inspectors wroteBased on administrative and medical record reviews and staff interview, it was determined that the facility failed to 1) maintain access to all closed medical records, and 2) maintain accurate electronic medical records. This was evident for 3 ( #35, #8, #26 ) of 51 resident records reviewed for accuracy during a complaint survey.

Inspectors wroteBased on surveyor review of closed clinical records, review of facility administrative records and interviews with the facility staff, it was determined that the facility staff failed to ensure Resident #172 was free from abuse. This finding was evident for 1 of 7 residents selected for review of the abuse care area, which resulted in actual harm. This finding was identified during the investigation of a facility reported incident MD00159216. A review of the facility's plan of correction implemented after the facility gained knowledge of the abuse incident resulted in the deficiency being cited as past non-compliance. The correction date was 10-14-2020.

Inspectors wroteBased on surveyor review of the clinical records, interviews with residents, resident's representatives and facility staff, it was determined that the facility failed to ensure timely interdisciplinary care conferences for residents. This finding was evident for 2 of 34 residents selected during the survey (Resident #26 and Resident #45).

Inspectors wroteBased on review of the clinical record, interview with Resident #26's representative and facility staff, it was determined that the facility failed to ensure standards of professional practice. This was evident for 1 of 34 residents selected for review during the survey (Resident #26).