Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Carroll Lutheran Village
WESTMINSTER, MD · 72 certified beds · Last Life Safety survey September 2, 2021
CMS Certification Number 215133 · first certified September 1981
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MD
7 citations — more than 3% of the 221 certified nursing homes in MD. Compared within MD rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys on file averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2022 to August 2025), and past the point by which nine in ten MD facilities have been surveyed. This facility’s last Life Safety survey was September 2021. Facilities in MD are typically surveyed 16–48 months after the last one (median 23), measured over 307 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 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.
How that compares
Compared with the median facility in MD, and nationally. Surveyors differ markedly between states, so the MD figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in MD | 23 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 26, 2017 | 0 |
| September 25, 2018 | 2 |
| September 2, 2021 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2018-09-25 |
| K-0271 | Have exits that are accessible at all times. | 1 | 2021-09-02 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2021-09-02 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2018-09-25 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2021-09-02 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2021-09-02 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2021-09-02 |
What the citations cover
- Smoke Deficiencies 4
- Egress Deficiencies 2
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 2, 2021 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (January 6, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 6, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 6, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 6, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 6, 2022) |
September 25, 2018 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 31, 2018) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 31, 2018) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.