Carroll Lutheran Village

CMS star ratings

Overall★★★★★ 5/5

State avg 3.1

Health inspections★★★★★ 4/5

State avg 2.8

Staffing★★★★★ 5/5

State avg 3.2

Quality measures★★★★★ 5/5

State avg 3.9

Long-stay quality★★★★★ 5/5

Short-stay quality★★★★★ 5/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing: 3.89 (state 3.87 · U.S. 3.86)
Registered nurses (RN): 1.03 (state 0.84 · U.S. 0.69)
Licensed practical nurses: 0.82 (state 0.91 · U.S. 0.86)
Nurse aides: 2.05 (state 2.12 · U.S. 2.32)
Weekend total: 3.67 (state 3.47 · U.S. 3.42)
Nursing staff turnover: 33.7 (state 40.2 · U.S. 45.8)%
RN turnover: 35.0 (state 38.7 · U.S. 42.9)%
Administrators who left: 0 in the last year

Inspections

Last standard inspection: June 6, 2025
Health deficiencies (last cycle): 6.0 (state 17.5 · U.S. 9.3)
From complaints: 0
Citations on record (3 years): 34 health · 7 fire safety

Date	Citation	Severity	Status
2025-06-06	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2025-07-03
2025-06-06	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-07-03
2025-06-06	Provide safe and appropriate respiratory care for a resident when needed. F0695 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-07-03
2025-06-06	Provide safe, appropriate pain management for a resident who requires such services. F0697 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-07-03
2025-06-06	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-07-03
2025-06-06	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-07-03
2021-09-02	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. F0726 · Nursing and Physician Services Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867 · Administration Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Ensure each resident receives an accurate assessment. F0641 · Resident Assessment and Care Planning Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Ensure services provided by the nursing facility meet professional standards of quality. F0658 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	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. F0758 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2021-09-02	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. F0925 · Environmental Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-10-20
2018-09-25	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	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. F0584 · Resident Rights Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	Prepare residents for a safe transfer or discharge from the nursing home. F0624 · Resident Rights Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	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. F0761 · Pharmacy Service Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. F0582 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	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. F0758 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2018-11-06
2018-09-25	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. F0623 · Resident Rights Deficiencies	C No actual harm, potential for minimal harm	Corrected 2018-11-06
2018-09-25	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. F0625 · Resident Rights Deficiencies	C No actual harm, potential for minimal harm	Corrected 2018-11-06

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

Name	Role	Since
Aegis Therapies, INC. (organization)	Administrator · NOT APPLICABLE
Cousins, Karen (individual)	Administrator · NOT APPLICABLE
Friends Services for the Aging (organization)	Administrator · NOT APPLICABLE
Martinez, Jose (individual)	Administrator · NOT APPLICABLE
Sodexho INC (organization)	Administrator · NOT APPLICABLE
Uttenreither, Heather (individual)	Administrator · NOT APPLICABLE
Branch, Jeffrey (individual)	Corporate Officer · NOT APPLICABLE
Powell, Steven (individual)	Corporate Officer · NOT APPLICABLE
Rosenheim, Michelle (individual)	Corporate Officer · NOT APPLICABLE
Branch, Jeffrey (individual)	Indirect Ownership Interest · NOT APPLICABLE
Cousins, Karen (individual)	Indirect Ownership Interest · NOT APPLICABLE
Martinez, Jose (individual)	Indirect Ownership Interest · NOT APPLICABLE
Carroll Lutheran Village INC (organization)	Operational/managerial Control · NOT APPLICABLE
Cousins, Karen (individual)	Operational/managerial Control · NOT APPLICABLE
Friends Services for the Aging (organization)	Operational/managerial Control · NOT APPLICABLE
Garvin, Renee (individual)	Operational/managerial Control · NOT APPLICABLE
Martinez, Jose (individual)	Operational/managerial Control · NOT APPLICABLE
Romeril, Kerrie (individual)	Operational/managerial Control · NOT APPLICABLE
Rosenheim, Michelle (individual)	Operational/managerial Control · NOT APPLICABLE
Sodexho INC (organization)	Operational/managerial Control · NOT APPLICABLE
Uttenreither, Heather (individual)	Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Carroll Lutheran Village?

Carroll Lutheran Village has a 5-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.1-star average in Maryland.

How many beds does Carroll Lutheran Village have?

It has 72 certified beds and cares for about 67 residents per day.

Has Carroll Lutheran Village been fined?

CMS lists no federal fines or payment denials in the last three years.

What is the phone number of Carroll Lutheran Village?

(410) 848-0225. The facility is located at 200 ST. Luke's Circle, Westminster, MD 21157.

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Contact & location

Facility details