01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-06-06 | 6 | 2021-09-02 | 5 |
| Cycle 2 | 2021-09-02 | 16 | 2018-09-25 | 2 |
| Cycle 3 | 2018-09-25 | 12 | 2017-06-26 | 0 |
CMS CCN 2151332026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Carroll Lutheran Village
200 St. Luke'S Circle · Westminster, MD 21157 · Carroll County
Certified beds72CMS provider file
Recent citation rows41current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
41 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-06-06 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-07-032025-06-06 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-07-032025-06-06 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-07-032025-06-06 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-07-032025-06-06 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-07-032025-06-06 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-07-032021-09-02 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0726Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0867Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · HEALTHF0925Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2021-10-202021-09-02 · FIREK0271Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2022-01-062021-09-02 · FIREK0293Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2022-01-0603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BRANCH, JEFFREYIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/08/2019
- COUSINS, KARENIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2025
- MARTINEZ, JOSEIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2025
- BRANCH, JEFFREYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/08/2019
- POWELL, STEVENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/02/2014
- ROSENHEIM, MICHELLEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/24/2025
- CARROLL LUTHERAN VILLAGE INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/10/1981
- FRIENDS SERVICES FOR THE AGINGOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2000
- SODEXHO INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2024
- COUSINS, KARENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2025
- GARVIN, RENEEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/27/2025
- MARTINEZ, JOSEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2025
- ROMERIL, KERRIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/14/2024
- ROSENHEIM, MICHELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/24/2025
- UTTENREITHER, HEATHERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/18/2023
- AEGIS THERAPIES, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 12/01/2023
- FRIENDS SERVICES FOR THE AGINGOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/10/2025
- SODEXHO INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/10/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.89per resident day
RN hours1.03per resident day
Weekend nurse hours3.67per resident day
Staff turnover33.7%CMS reported field
06 / LOCAL RECORDS
Open the Westminster ledger →