Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carroll Lutheran Village during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food storage and labeling, including items with incomplete date labels, expired bread, and an open container lacking an open date. Additionally, cold storage was found with ice accumulation on the floor and boxes stacked too close to the ceiling. These issues were confirmed by dietary staff and reviewed with facility administration.
A resident's care plans were not reviewed and revised by all required IDT members during multiple assessment periods, as both the GNA and physician did not participate in care plan meetings. This resulted in incomplete interdisciplinary input for the resident's ongoing care planning.
Staff did not label or document the date, time, or initials on a resident's oxygen tubing and humidifier bottle after changing them, despite physician orders requiring weekly changes and proper labeling. Although records indicated the equipment was changed, the absence of labeling on the equipment itself failed to verify compliance.
A resident with multiple complex medical conditions did not receive pain management in accordance with physician orders and professional standards. PRN Oxycodone was administered for pain scores below the ordered threshold, and PRN Tylenol was given without defined parameters. Nursing staff did not document reasons for administering Oxycodone outside of prescribed parameters, and the DON confirmed these deficiencies.
A medication security deficiency was identified when a prescribed medication was found unattended in a medication cup on a resident's bedside table, along with a half-empty cup of water. The medication, intended for acid reflux, was left by a previous shift and not administered as the resident was unable to swallow it whole and usually requested it to be crushed. The medication and water were later discarded by an RN.
A resident admitted for short-term rehab left the facility against medical advice after expressing concerns about having a new roommate. Although staff reported discussing alternative arrangements, such as a private room, there was no documentation in the medical record reflecting these communications or the resident's response. The DON and NHA acknowledged the lack of documentation.
Deficient Food Storage, Labeling, and Cold Storage Practices Identified
Penalty
Summary
Surveyors observed several deficiencies in the facility's kitchen related to food storage and labeling practices. Caramel topping and black mission figs were found with date labels that did not include the year, and an open container of orange natural flavor extract lacked an open date. Bread rolls and hot dog bread were found with expiration dates, with the hot dog bread already expired. Dietary staff confirmed that their labeling system could not include the year and acknowledged the need for a different process to ensure complete date labeling. Staff also reported that bread expiration checks were not performed daily, as they were skipped on Sundays. Additional observations in the cold storage area revealed small pieces of ice on the floor, creating a wet and slippery surface. Furthermore, boxes were stacked on storage shelves up to the ceiling, leaving less than an inch of clearance. These findings were reviewed with dietary staff and the nursing home administrator during the survey.
Failure to Include All Required IDT Members in Care Plan Reviews
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by all required Interdisciplinary Team (IDT) members when quarterly, annual, and significant change assessments were completed. Specifically, for one resident who had been receiving long-term care for over a year, comprehensive assessments were conducted on four separate occasions. However, documentation revealed that the Geriatric Nursing Assistant (GNA) and the physician did not participate in the care plan meetings for these assessments, as their signatures were absent from the care plan attendance records. This deficiency was identified through medical record review and staff interviews, which confirmed the lack of participation by the GNA and physician in the care planning process. The absence of these required team members during care plan reviews and revisions meant that the care plans may not have fully reflected the input of all disciplines as required by regulation.
Failure to Label and Document Oxygen Tubing and Humidifier Changes
Penalty
Summary
Facility staff failed to follow physician orders regarding the labeling and changing of oxygen tubing and humidifier bottles for a resident receiving continuous oxygen therapy. During an observation, a resident was found using a nasal cannula connected to a humidifier bottle and oxygen concentrator, but neither the tubing nor the bottle was labeled with the date, time, or staff initials as required. The resident could not recall the exact date the equipment was last changed, and a registered nurse confirmed that the items were not labeled as per protocol. A review of the resident's medical record revealed active physician orders specifying that the oxygen tubing and humidifier bottle should be changed weekly, dated, and initialed by staff. Documentation in the Medication Administration Record and Treatment Administration Record indicated that the equipment was changed on the appropriate day, but the lack of labeling on the actual equipment did not provide verification of compliance with the orders. The Director of Nursing acknowledged the deficiency during the survey.
Failure to Follow PRN Pain Medication Parameters and Documentation Standards
Penalty
Summary
Facility staff failed to provide pain management services consistent with professional standards of practice for a resident admitted with multiple medical diagnoses, including a right femur fracture, atrial fibrillation, COPD with exacerbation, and respiratory failure. The resident had physician orders for PRN Tylenol 325 mg (2 tablets every 4 hours as needed, not to exceed 3000 mg/day) without specific administration parameters, and for PRN Oxycodone 5 mg (1 tablet every 6 hours as needed for pain scores 6-10). Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that Oxycodone was administered multiple times for pain scores below the ordered threshold (pain scores of 4 or 5), which was outside the prescribed parameters. Additionally, PRN Tylenol was administered 17 times for pain scores ranging from 3 to 8, despite the absence of defined parameters for its use. Interviews with nursing staff confirmed that pain medication should be administered according to physician-ordered parameters, and deviations from these parameters should be documented and justified in the resident's progress notes. However, there was no documentation explaining why Oxycodone was given outside the ordered parameters. The Director of Nursing verified these findings and acknowledged the lack of documentation and the absence of administration parameters for PRN Tylenol.
Medication Security Deficiency Due to Unattended Medication at Bedside
Penalty
Summary
A medication security deficiency occurred when a round pink medication, later identified as TUMs (Calcium Carbonate), was found in a medication cup on a resident's bedside table along with a half-empty cup of water during an initial facility tour. The resident was not present in the room at the time. A registered nurse confirmed the medication was prescribed for acid reflux and stated it was likely left by the night shift nurse. Review of the resident's Medication Administration Record showed the medication was signed as given the previous night. Upon interview, the resident reported being unable to swallow the medication due to its size and typically requested it to be crushed. The medication and water were subsequently discarded by the nurse.
Failure to Document Staff Communication Regarding Roommate and Discharge
Penalty
Summary
The facility failed to ensure accurate documentation of staff communication with a resident regarding the admission of a new roommate. Medical record review showed that the resident was admitted for short-term rehabilitation and later left the facility against medical advice. There was no documentation in the medical record reflecting staff communication with the resident about the new roommate or the alternatives offered to the resident when concerns were raised about having a roommate. Interviews with staff revealed that the admission coordinator and other staff members communicated with the resident about the new roommate and discussed possible alternative arrangements, such as a private room. However, none of these communications were documented in the resident's medical record. The DON and the Nursing Home Administrator acknowledged the lack of documentation regarding these interactions and the resident's discharge against medical advice.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,098 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westminster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlee Hill Health And Rehab Center | 0.4 mi | ★★★★★ | 41 | 0 |
| Westminster Rehabilitation And Wellness Center | 1 mi | ★★★★★ | 9 | 0 |
| Autumn Lake Healthcare At Long View | 9.4 mi | ★★★★★ | 13 | 0 |
| Lorien Taneytown, Inc | 11 mi | ★★★★★ | 33 | 0 |
| Future Care Cherrywood | 11.7 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Carroll Lutheran Village.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.