Cycle 1
Health 2025-06-26 · Fire 2025-06-26
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Ellicott City, MD
The Lutheran Village At Miller's Grant
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
9120 Fathers Legacy, Ellicott City, MD
(410) 696-6700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
16
Certified beds
Average residents
13
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-04-18
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
1.56
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
2.32
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
4.61
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
1.16
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.46
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 41% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 76 |
| Staff flu vaccination coverage | 99.14% |
42%
57.1 pts better
|
Numerator 115 · Denominator 116 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.3%
2.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
21.4%
18.6 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.9% |
16.1%
26.8 pts worse
|
19.6%
23.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 42.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 50.0% |
15.3%
34.7 pts worse
|
16.7%
33.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 50.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
22.9%
3.9 pts better
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
1.5%
4.2 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.9% |
25.4%
19.5 pts better
|
19.8%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
6.3%
3 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
78.4%
14.5 pts better
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 92.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.1% |
1.3%
5.8 pts worse
|
1.6%
5.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-02 · Fire 2022-09-02
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
9 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2019-05-22 · Fire 2019-05-22
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-06-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-06-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-06-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-06-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-08-25
E · Potential for more than minimal harm
2022-09-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-09-02
K224 · Egress Deficiencies
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-09-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-09-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-09-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-09-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-09-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-11
C · Minimal harm
2022-09-02
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-12-14
C · Minimal harm
2022-09-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-12-14
C · Minimal harm
2019-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-26
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 2025-07-25
D · Potential for more than minimal harm
2025-06-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-26
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-07-25
F · Potential for more than minimal harm
2022-09-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-31
F · Potential for more than minimal harm
2022-09-02
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 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
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 2022-10-31
D · Potential for more than minimal harm
2022-09-02
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 2022-10-31
D · Potential for more than minimal harm
2022-09-02
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 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-02
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-10-31
C · Minimal harm
2022-09-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-10-31
Penalties and ownership
What sits behind the stars
Ownership
Branch, Jeffrey
Operational/Managerial Control · Individual
Branch, Jeffrey
Corporate Officer · Individual
Friends Services For The Aging
Operational/Managerial Control · Organization
Rosenheim, Michelle
Operational/Managerial Control · Individual
Scherr, Nicole
Operational/Managerial Control · Individual
Sodexho Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Ellicott City Healthcare Center
Ellicott City, MD
2-star overall rating with 1-star inspections with 37 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Residences At Vantage Point
Columbia, MD
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Encore At Turf Valley
Ellicott City, MD
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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