CARROLL LUTHERAN VILLAGE

WESTMINSTER, MD · 103 beds · Non profit - Corporation

100 Trust Score
Grade: A+ LOW Risk → Stable

Red Flags

No red flags identified.

Green Flags

  • 4-star health inspection rating
  • 5-star staffing rating
  • Below-average deficiency count (6 vs 19 state avg)
  • No fines or penalties on record
  • Above-average RN staffing (1.17 hrs vs 0.81 state avg)

Quick Facts

★★★★★
CMS Overall
★★★★☆
Health Inspection
6
0.3x state avg
Deficiencies
$0
Fines (3-yr)
★★★★★
Staffing

Violation Timeline

June 5, 2025

6 deficiencyies
F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe and appropriate respiratory care for a resident when needed.

F0697 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe, appropriate pain management for a resident who requires such services.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0812 Potential Harm Scope/Severity: E

Nutrition and Dietary Deficiencies

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

F0842 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

September 1, 2021

14 deficiencyies
F0550 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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

F0641 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Ensure each resident receives an accurate assessment.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0658 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Ensure services provided by the nursing facility meet professional standards of quality.

F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0726 Potential Harm Scope/Severity: F

Nursing and Physician Services Deficiencies

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Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

F0757 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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

F0842 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

F0867 Potential Harm Scope/Severity: F

Administration Deficiencies

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Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

See full violation history →

Staffing

1.17
RN hrs/res/day
0.87
LPN hrs/res/day
2.31
CNA hrs/res/day
4.10
Weekend hrs/res/day
39%
Total nurse turnover
30%
RN turnover

A nurse checks on each resident roughly every 5.5 hours on average.

Fines & Penalties

No fines or penalties on record.

Ownership

Non profit - Corporation Independent (not part of a chain)
  • CARROLL LUTHERAN VILLAGE INC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 09/10/1981

    Organization
  • FRIENDS SERVICES FOR THE AGING

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2000

    Organization
  • SODEXHO INC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 05/01/2024

    Organization
  • COUSINS, KAREN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 04/01/2025

    Individual
  • GARVIN, RENEE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/27/2025

    Individual
  • MARTINEZ, JOSE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 04/01/2025

    Individual
  • ROMERIL, KERRIE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/14/2024

    Individual
  • ROSENHEIM, MICHELLE

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 06/24/2025

    Individual
  • UTTENREITHER, HEATHER

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 08/18/2023

    Individual
  • BRANCH, JEFFREY

    CORPORATE OFFICER

    Since since 07/08/2019

    Individual
  • POWELL, STEVEN

    CORPORATE OFFICER

    Since since 06/02/2014

    Individual
  • ROSENHEIM, MICHELLE

    CORPORATE OFFICER

    Since since 06/24/2025

    Individual

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