Cycle 1
Health 2025-06-06 · Fire 2021-09-02
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Westminster, MD
Carroll Lutheran Village
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
200 St. Luke's Circle, Westminster, MD
(410) 848-0225
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
65
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-09-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.17
CMS adjusted RN staffing hours
Adjusted total hours
4.34
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
847
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0178
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.48
Baseline 20.50% · Performance 17.50% · Measure score 8.48 · Achievement 8.48 · Improvement 8.14
Healthcare-associated infections
8.52
Baseline 5.27% · Performance 5.29% · Measure score 8.52 · Achievement 8.52 · Improvement 0
Total nurse turnover
5.43
Performance 41.49% · Measure score 5.43 · Achievement 5.43 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.77
Baseline 3.92 hours · Performance 3.87 hours · Measure score 2.77 · Achievement 2.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 280 · Observed rate 8.93% · Lower 95% interval 7.98% |
| Discharge to community | 71.87% |
50.57%
21.3 pts better
|
Better than the National Rate · Eligible stays 259 · Observed rate 71.04% · Lower 95% interval 67.35% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 88.49% |
95.27%
6.8 pts worse
|
Numerator 123 · Denominator 139 |
| Falls with major injury | 1.44% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 139 |
| Discharge self-care score | 43.22% |
53.69%
10.5 pts worse
|
Numerator 51 · Denominator 118 |
| Discharge mobility score | 41.53% |
50.94%
9.4 pts worse
|
Numerator 49 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 3.6% |
2.29%
1.3 pts worse
|
Numerator 5 · Denominator 139 · Adjusted rate 4.24% |
| Healthcare-associated infections requiring hospitalization | 5.29% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 2.34% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 8% |
8.2%
0.2 pts worse
|
Numerator 12 · Denominator 150 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 211 · Denominator 211 |
| Discharge function score | 46.61% |
56.45%
9.8 pts worse
|
Numerator 55 · Denominator 118 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.94% |
96.28%
0.7 pts better
|
Numerator 95 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 77.27% |
25.2%
52.1 pts better
|
Numerator 51 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.9%
8.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
2.3%
0.8 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 2.2% · Q4 2.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
21.4%
20.2 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 2.3% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
5.7%
4.5 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.6% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.5% |
16.1%
13.6 pts better
|
19.6%
17.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 0.0% · Q4 5.3% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
15.3%
10.9 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.4% · Q3 5.9% · Q4 5.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.0% |
26.6%
0.6 pts better
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 47.1% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.7% |
22.9%
2.8 pts worse
|
14.9%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 27.8% · Q3 13.5% · Q4 35.1% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.7%
0.5 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.5%
1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
25.4%
0.9 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 28.1% · Q3 15.3% · Q4 38.1% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
6.3%
0.4 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 5.0% · Q3 6.8% · Q4 5.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
78.4%
21.4 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.2% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
9.9%
0.6 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.5% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
80.6%
16 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.3% |
21.2%
7.9 pts better
|
23.9%
10.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 11.0% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-02 · Fire 2018-09-25
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-09-25 · Fire 2017-06-26
12 health deficiencies
Top issue: Resident Rights (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-09-02
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-09-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-09-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-09-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-06
C · Minimal harm
2021-09-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-01-06
E · Potential for more than minimal harm
2018-09-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-10-31
E · Potential for more than minimal harm
2018-09-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-10-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-06
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-03
F · Potential for more than minimal harm
2021-09-02
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-10-20
F · Potential for more than minimal harm
2021-09-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-10-20
E · Potential for more than minimal harm
2021-09-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-10-20
E · Potential for more than minimal harm
2021-09-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-10-20
E · Potential for more than minimal harm
2021-09-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-10-20
D · Potential for more than minimal harm
2021-09-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2021-10-20
F · Potential for more than minimal harm
2018-09-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-11-06
E · Potential for more than minimal harm
2018-09-25
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2018-11-06
E · Potential for more than minimal harm
2018-09-25
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2018-11-06
E · Potential for more than minimal harm
2018-09-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-25
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2018-11-06
C · Minimal harm
2018-09-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-11-06
C · Minimal harm
2018-09-25
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2018-11-06
Penalties and ownership
What sits behind the stars
Ownership
Branch, Jeffrey
Corporate Officer · Individual
Carroll Lutheran Village Inc
Operational/Managerial Control · Organization
Cousins, Karen
Operational/Managerial Control · Individual
Friends Services For The Aging
Operational/Managerial Control · Organization
Garvin, Renee
Operational/Managerial Control · Individual
Martinez, Jose
Operational/Managerial Control · Individual
Powell, Steven
Corporate Officer · Individual
Romeril, Kerrie
Operational/Managerial Control · Individual
Rosenheim, Michelle
Operational/Managerial Control · Individual
Rosenheim, Michelle
Corporate Officer · Individual
Sodexho Inc
Operational/Managerial Control · Organization
Uttenreither, Heather
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Atlee Hill Health And Rehab Center
Westminster, MD
2-star overall rating with 2-star inspections with $14,888 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Westminster Healthcare Center
Westminster, MD
2-star overall rating with 2-star inspections with abuse icon flag with $63,681 in total fines with 7 recent health deficiencies
#3
Autumn Lake Healthcare At Long View
Manchester, MD
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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