Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadow Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A facility failed to protect resident dignity when a dry erase board visible from the hallway and nurse's station publicly identified multiple residents as feeders by room number. Staff confirmed the board was used to list residents needing feeding assistance, and interviews showed awareness that the term was inappropriate and privacy concerns existed. The facility policy stated residents should not be labeled by room number, diagnosis, or care needs.
Failure to Properly Handle Allegation of Verbal Abuse: A resident with dementia, hemiplegia, HIV disease, dysphagia, and cognitive communication deficits had an anonymous allegation that the resident’s daughter was verbally abusive. Facility records showed the Administrator and staff notified police, the resident’s representative who was also the alleged perpetrator, and the Ombudsman, but the investigation was compromised because the alleged perpetrator was informed. Interviews confirmed leadership’s standard practice was to tell the family member about the allegation, despite acknowledging this could affect the investigation.
A resident with chronic respiratory failure, COPD, OSA, CKD, and malnutrition experienced an early-morning change in condition and later died, but the EMR was inconsistent and incomplete. An LPN documented and later verbally changed the oxygen saturation reading, used CPAP terminology despite a Bi-PAP order, and added unrecorded details about oxygen equipment alarms and switching from a concentrator to an oxygen tank; there was also no documentation of the nurse’s presence, assessment, or monitoring after phlebotomy, and the provider was not notified before the resident’s death.
Failure to Use Required PPE During EBP: Staff did not follow EBP requirements for two residents with signs posted on their doors. A GNA handled trash, provided dressing and transfer assistance, and later performed incontinent care without the required gown and gloves, and an OT provided skin-to-skin contact during therapy without PPE. The DON confirmed that gown and gloves were required for high-contact care, including therapy contact.
A cognitively impaired, wheelchair-bound resident with a history of exit-seeking behavior and a Stage III heel wound was able to leave the facility unsupervised when the WanderGuard system and front door malfunctioned. Staff did not detect the resident's exit, and the individual was later found by police outside the facility. Documentation showed a delay in reporting the incident and a decline in the resident's wound condition following the event.
A resident reported not receiving written notification before a roommate change, expressing concern about a violation of their rights. Facility leadership confirmed that only verbal notification was provided for room changes, and acknowledged this did not meet regulatory requirements for written notice.
Facility staff did not report a resident's elopement to the state agency within the required two-hour window. The Administrator and DON, who are responsible for reporting, delayed notification because the incident occurred at night and prioritized ensuring the resident's safety before making the report. The facility did not have a policy in place for incident reporting.
Facility staff did not thoroughly investigate two separate abuse allegations made by a resident, including rough care during medication administration and nose drop dispensing. When requested, the facility could not provide investigation records for either incident, as required by CMS policy.
A resident's medical record contained conflicting information, with documentation showing both a complete traumatic amputation of the left lower leg and a left heel wound. This inconsistency was identified during a survey and confirmed through interviews with facility leadership, revealing a failure to ensure accurate and consistent medical recordkeeping.
Publicly Labeling Residents on a Visible Board
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when staff publicly labeled residents as feeders on a dry erase board visible from the hallway and nurse's station. During multiple observations, the surveyor saw a board on the second floor next to the nurse's station listing the room numbers of Residents #23 through #35 under a heading identifying them as feeders, making their care needs visible to staff, visitors, and anyone passing through the area. This practice affected Residents #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35. During interviews, GNA #15 stated that residents who are total care receive assistance with feeding and acknowledged the term feeders is used. GNA #8 stated that feeders refers to residents needing assistance with eating and acknowledged staff should not refer to residents as feeders on the board due to privacy concerns. GNA #11 confirmed residents requiring feeding assistance were identified by room number on the dry erase board and that the sign was visible for everyone to see. GNA #10 stated the board identifies feeders and their room numbers. The facility policy titled Dignity stated staff speak respectfully to residents at all times and do not label or refer to residents by room number, diagnosis, or care needs.
Failure to Properly Handle Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported and handled in accordance with CMS requirements. Resident #12 was admitted with diagnoses including dementia with behavioral disturbance, hemiplegia, HIV disease, dysphagia, and cognitive communication deficits. An anonymous allegation was received that the resident’s daughter was verbally abusive toward the resident. Facility documentation showed staff and the Administrator became aware of the allegation, contacted the local police department, reported the allegation to the resident’s representative who was also the alleged perpetrator, and notified the local Ombudsman’s office. The facility documented that the allegation was not verified, but also stated the investigation was compromised because the alleged perpetrator was notified. There was no documentation that the resident was protected from potential retaliation during the investigation. During interviews, the ADON stated that if the alleged abuser is in the building, the facility removes them but does not tell them about the allegation, while the DON stated that when the alleged perpetrator is a family member, the facility does not say who the allegation is about, although the Administrator may have done so. The Administrator confirmed that the resident’s representative, who was the alleged perpetrator, was told there was an allegation of abuse against them and stated this was standard practice.
Inaccurate and Inconsistent Clinical Documentation During Resident Change in Condition
Penalty
Summary
The facility failed to ensure the clinical record was accurate, complete, and consistent for one resident who had diagnoses including chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, CKD, and malnutrition. During the early morning change in condition, the vital sign log documented an oxygen saturation of 60% at 4:45 a.m., and an LPN later documented that the resident was found unresponsive, CPR was started at 5:52 a.m. with an AED, EMS was called at 5:53 a.m., and the resident was pronounced deceased at 6:25 a.m. However, the nurse’s account changed during interviews, including later stating the oxygen saturation had been 90% rather than 60%, and adding that the oxygen concentrator was alarming and the resident was switched to an oxygen tank, which had not been previously reported or documented in the EMR. The record also showed inconsistency between the physician’s order for Bi-PAP and the nurse’s documentation and statements referring to CPAP. The LPN stated the resident was not wearing the Bi-PAP at 11 p.m., that there was no documentation of refusal, and that CPAP was applied around 1:00 a.m. The nurse supervisor stated the LPN reported the resident was unresponsive and did not mention any prior low oxygen saturation, alarms, or equipment issues, and the provider stated they were not notified of any change in condition before being told the resident had expired. The contracted laboratory COO stated a facility staff member accompanies the phlebotomist to verify identity, but there was no documentation in the EMR of the nurse’s presence, assessment, or post-phlebotomy monitoring.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program that would prevent and protect residents from the risk of infection for two residents. The deficiency involved Enhanced Barrier Precautions (EBPs), which the facility policy described as requiring targeted gown and glove use during high-contact resident care activities, with PPE applied before the activity and changed before caring for another resident. The policy also stated that signs are posted on the door or wall outside residents’ rooms to communicate the precautions and PPE required. Resident #15 had an EBP sign posted on the room door, but on 4/27/26 GNA #7 threw away trash outside the room without wearing PPE and then returned to the resident’s bedside without hand hygiene or PPE to continue care behind the privacy curtain. Later that day, the same aide assisted the resident with dressing and transferring from bed to wheelchair without putting on the required PPE. During interview, GNA #7 acknowledged that PPE was required for direct care and confirmed that PPE was not worn during the dressing and transfer assistance. Resident #14 was admitted on 4/16/26 with diagnoses including fracture of the neck of the right femur, muscle wasting and atrophy, chronic kidney disease, and acute pulmonary edema. The resident had physician orders dated 4/27/26 for EBPs due to an indwelling catheter and wound. On 4/27/26, OT #12 worked with the resident on upper extremity exercises and placed hands on the resident’s bare arm to assist with lifting weights, but did not wear PPE. On 4/28/26, GNA #14 was observed providing care behind the resident’s privacy curtain with an EBP sign posted, and later removed gloves after changing the resident’s brief without wearing a gown. Interviews confirmed that OT #12 did not wear PPE during therapy contact and that GNA #14 did not wear a gown during incontinent care.
Failure to Prevent Elopement of Cognitively Impaired Resident Due to Monitoring and System Failures
Penalty
Summary
Facility staff failed to adequately monitor a cognitively impaired resident with known exit-seeking behaviors, resulting in the resident leaving the building unsupervised. The resident, who was wheelchair-bound with a right below-knee amputation and a Stage III left heel wound, had previously attempted to elope and was assessed as needing a Wanderguard bracelet. Despite these interventions, the resident was able to exit the facility through the front entrance when the WanderGuard system failed to alarm due to a power surge and a malfunctioning door. Staff did not hear any alarms, and the resident was not located within the facility or on the grounds, prompting notification of local authorities. The resident was found by police several hours later near a highway exit and returned to the facility. Documentation revealed a delay in reporting the incident to the state agency, as well as a lack of wound measurements for the resident in the days following the elopement, with subsequent documentation showing a decline in the wound's condition. Interviews with facility staff indicated uncertainty about the cause of the door malfunction and the effectiveness of the WanderGuard system during power surges. The incident was determined to be Immediate Jeopardy past non-compliance.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to implement a process to ensure residents receive written notice prior to room or roommate changes, as required by regulation. During the recertification survey, one resident reported not receiving written notification regarding changes in their roommate, expressing concern that this violated their rights. Interviews with the DON and Administrator confirmed that the facility's practice was to provide only verbal notification of room changes, and documentation provided supported this. The DON acknowledged that this practice did not meet the regulatory requirement for written notification.
Failure to Timely Report Resident Elopement
Penalty
Summary
Facility staff failed to report a resident elopement to the state agency within the required two-hour timeframe. The incident occurred at 12:30 AM, and the Administrator and DON were notified at 1:45 AM, but the report to the state agency was not made until 12:19 AM the following day, exceeding the mandated reporting window. During interviews, the Administrator stated that there was no current policy for reporting such incidents and that both the Administrator and DON are responsible for reporting. The delay was attributed to the incident occurring at night and the Administrator prioritizing getting to the facility to ensure the resident's safety before reporting.
Failure to Investigate and Retain Records for Abuse Allegations
Penalty
Summary
Facility staff failed to thoroughly investigate two separate allegations of abuse made by a resident. The first incident involved a nursing staff member allegedly prying medications out of the resident's left hand during a medication pass, and the second involved the same resident reporting rough care when nose drops were administered. Upon request, the facility was unable to provide the investigations for either incident, as confirmed by the Administrator, who stated that the incidents occurred prior to the current administration. The surveyor noted that CMS policy requires facilities to retain records of any facility-reported incidents for at least five years after the investigation is closed.
Inaccurate Medical Record Documentation for Resident with Amputation
Penalty
Summary
Facility staff failed to ensure the accuracy of a resident's medical record, as evidenced by conflicting documentation regarding the resident's condition. The electronic medical record indicated that the resident had a complete traumatic amputation of the left lower leg, while a skin assessment documented a left heel wound for the same resident. This discrepancy was identified during a review of the resident's records and confirmed through interviews with the Administrator, who stated that the admissions nurse is responsible for entering medical information based on the discharge summary, and the MDS Coordinator is responsible for checking the accuracy of the information entered. The deficiency was found during a recertification survey, where the inconsistency between the resident's diagnosis and wound documentation was observed and discussed with facility leadership.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frederick Villa Healthcare | 2.2 mi | ★★★★★ | 62 | 0 |
| Forest Haven Nursing And Rehabilitation Ctr | 2.3 mi | ★★★★★ | 54 | 0 |
| Autumn Lake Healthcare At Catonsville | 2.4 mi | ★★★★★ | 41 | 0 |
| Autumn Lake Healthcare At Summit Park | 2.6 mi | ★★★★★ | 26 | 0 |
| Ridgeway Rehab Center | 2.6 mi | ★★★★★ | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.