The Vardell Report.Turtle Creek Rehabilitation and Wellness Center

Across 7 inspections from November 2020 to August 2026, state surveyors documented 62 findings at Turtle Creek Rehabilitation and Wellness Center; 58 have a recorded correction and 4 await one; CMS lists 2 enforcement actions in the window.

Inspections

7

2020–2026, complaint and standard

Findings

62

Deficiencies cited by state inspectors

Corrected

58

Of 62 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 262026

   Complaint investigation

   4 findings

   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 102026

   Complaint investigation

   2 findings

   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 10, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 10, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Apr 222026

   Standard health inspection

   15 findings

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jun 8, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jun 8, 2026
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Jun 8, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Feb 92026

   Complaint investigation

   4 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level LImmediate jeopardyCorrected Mar 13, 2026
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level DNo actual harm, potential for moreCorrected Mar 13, 2026
   • F946Provide training in compliance and ethics.Level DNo actual harm, potential for moreCorrected Mar 13, 2026
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Mar 13, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Feb 272025

   Standard health inspection

   20 findings

   The same visit included a complaint investigation.

   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Apr 30, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Apr 30, 2025
   • F910Ensure resident rooms meet each resident's needs.Level ENo actual harm, potential for moreCorrected Apr 30, 2025
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Apr 30, 2025

   Enforcement Action

   Civil money penalty, $28,880 imposed February 9, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 27, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Oct 22024

   Complaint investigation

   14 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Dec 12, 2024
   • F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level FNo actual harm, potential for moreCorrected Jan 10, 2025
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Dec 12, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Dec 12, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Dec 12, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Dec 12, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Dec 12, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Dec 12, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
   • F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Dec 12, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Dec 12, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Nov 22020

   Standard health inspection

   3 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Oct 15, 2020
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Dec 16, 2020
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 16, 2020

   Enforcement Action

   Civil money penalty, $51,545 imposed October 2, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 2, 2020, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in October 2024, February 2025 and April 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F550 across all 7 inspections, oldest to newest
2. 2

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in November 2020, October 2024 and April 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F657 across all 7 inspections, oldest to newest
3. 3

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in October 2024, February 2025 and April 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F684 across all 7 inspections, oldest to newest
4. 4

   Treatment Choices and Advance Directives, Cited in Two Inspections

   Inspectors cited F578 in February 2025 and April 2026. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F578 across all 7 inspections, oldest to newest
5. 5

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in October 2024 and June 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F580 across all 7 inspections, oldest to newest
6. 6

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in November 2020 and October 2024. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F600 across all 7 inspections, oldest to newest
7. 7

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in February 2025 and June 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F610 across all 7 inspections, oldest to newest
8. 8

   Professional Standards, Cited in Two Inspections

   Inspectors cited F658 in November 2020 and April 2026. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F658 across all 7 inspections, oldest to newest
9. 9

   Citation F660, Cited in Two Inspections

   Inspectors cited F660 in October 2024 and February 2025. The agency describes it this way: Plan the resident's discharge to meet the resident's goals and needs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   20242526262626F660 across all 7 inspections, oldest to newest
10. 10

    Pressure Injury Care, Cited in Two Inspections

    Inspectors cited F686 in October 2024 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    20242526262626F686 across all 7 inspections, oldest to newest
11. 11

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in February 2025 and April 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    20242526262626F759 across all 7 inspections, oldest to newest
12. 12

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in October 2024 and February 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    20242526262626F842 across all 7 inspections, oldest to newest
13. 13

    Needs and Preferences, No Recorded Correction

    F558 was cited in August 2026. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    20242526262626F558 across all 7 inspections, oldest to newest
14. 14

    A Clean, Homelike Setting, No Recorded Correction

    F584 was cited in October 2024, February 2025 and August 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    20242526262626F584 across all 7 inspections, oldest to newest
15. 15

    Care Plans, No Recorded Correction

    F656 was cited in October 2024 and August 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    20242526262626F656 across all 7 inspections, oldest to newest
16. 16

    Accident Hazards and Supervision, No Recorded Correction

    F689 was cited in February 2026 and August 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level L (immediate jeopardy). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

    20242526262626F689 across all 7 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in three inspections, most seriously at level D.

2. 02

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in three inspections, most seriously at level E.

3. 03

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in three inspections, most seriously at level E.

4. 04

   How are a resident’s advance directive and treatment wishes recorded and shared with every shift?

   Treatment Choices and Advance Directives: cited in two inspections, most seriously at level D.

5. 05

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in two inspections, most seriously at level D.

6. 06

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in two inspections, most seriously at level G.

7. 07

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in two inspections, most seriously at level D.

8. 08

   How do you check that nurses and aides follow professional standards, and what happens when they do not?

   Professional Standards: cited in two inspections, most seriously at level D.

9. 09

   What changed after F660 was cited, and how do you check it now?

   Citation F660: cited in two inspections, most seriously at level D.

10. 10

    How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

    Pressure Injury Care: cited in two inspections, most seriously at level E.

11. 11

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level D.

12. 12

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level D.

13. 13

    How do you adjust rooms, schedules and routines to a resident’s needs and preferences?

    Needs and Preferences: cited in one inspections, most seriously at level D. The August 26, 2026 citation has no recorded correction date.

14. 14

    What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

    A Clean, Homelike Setting: cited in three inspections, most seriously at level E. The August 26, 2026 citation has no recorded correction date.

15. 15

    How is a care plan written and reviewed here, and how do families take part in it?

    Care Plans: cited in two inspections, most seriously at level D. The August 26, 2026 citation has no recorded correction date.

16. 16

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in two inspections, most seriously at level L. The August 26, 2026 citation has no recorded correction date.

17. 17

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in February 2025.

18. 18

    What led to the 2026 fine, and has it been paid?

    A $28,880 civil money penalty was imposed February 9, 2026. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Maryland state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Nov 2, 2020 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Oct 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Feb 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Feb 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Apr 22, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Jun 10, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Aug 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 215043

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.