Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Diversicare Of Luling during CMS and state inspections, most recent first.
Dietary staff failed to follow proper hand hygiene protocols during food preparation and meal distribution, including not washing hands after touching contaminated items such as cleaning cloths and clothing, and then handling food containers, cups, and trays without gloves or handwashing. Staff interviews confirmed awareness of hand hygiene expectations, and facility policy requires handwashing between tasks and after contact with contaminated surfaces.
Surveyors found that garbage in the kitchen was left uncovered and overflowing near clean dishes and food prep areas, contrary to facility policy requiring covered containers during meal service. Staff interviews revealed inconsistent practices and understanding regarding proper garbage disposal, with some staff acknowledging the need for covered containers and others stating uncovered garbage was acceptable. The facility's policy mandates covered, leak-proof containers to prevent cross-contamination, but this was not followed.
Staff failed to disinfect shared equipment between residents and did not use required Enhanced Barrier Precautions during wound care for a resident with a chronic wound. Multiple staff, including a medication aide and two nurses, did not follow established infection control protocols, and leadership confirmed these lapses during interviews.
A resident with chronic respiratory conditions had a physician's order for oxygen as needed, but this intervention was not included in the comprehensive care plan or in the electronic records accessed by CNAs. Staff interviews confirmed that the omission led to a lack of awareness among CNAs about the resident's oxygen needs, as they relied solely on the care plan for care instructions. The MDS Coordinator and DON acknowledged the care plan was not updated as required, resulting in a risk of the resident not receiving appropriate care.
A resident with acute respiratory failure and severe cognitive impairment did not receive continuous oxygen therapy as ordered when her oxygen concentrator was left in a common area during a transfer, resulting in her being without oxygen for an extended period. Staff interviews revealed unclear communication and lack of recent training on oxygen care, leading to a lapse in safe and appropriate respiratory care.
A bottle of expired Aspirin was found in the medication storage room, revealing a lapse in the facility's pharmaceutical services and medication management procedures. Staff interviews showed uncertainty about who was responsible for checking and removing expired medications, and facility policy required such medications to be removed from inventory.
The facility failed to maintain proper hand hygiene in the kitchen, as observed with an employee not sanitizing or washing hands between tasks and not changing gloves after touching contaminated surfaces. Despite monthly training on hand hygiene, these actions were not in line with the facility's policies, potentially putting residents at risk of illness.
The facility failed to provide a private space for resident council meetings, holding them in the dining room where staff interruptions were frequent. Despite efforts by the Activity Director to prevent these interruptions, residents expressed dissatisfaction and felt disrespected. The Administrator acknowledged the lack of space but recognized the residents' right to meet privately.
The facility failed to assist three residents with personal hygiene and grooming, resulting in deficiencies. A female resident with cerebral infarction had unremoved facial hair despite family requests. A male resident with hemiplegia and diabetes had untrimmed, dirty nails, posing an infection risk. Another female resident had long, dirty nails and expressed embarrassment. Staff interviews confirmed the responsibility for nail care and facial hair removal, but care was not provided timely.
The facility failed to maintain proper infection control as staff did not follow hand hygiene procedures during dining services. A Speech Therapist and a CNA were observed not sanitizing or washing their hands after touching contaminated items before handling food for three residents, risking food contamination. Interviews revealed staff were aware of protocols but did not adhere to them, despite regular training on hand hygiene.
A cook improperly prepared pureed hamburger meat by mixing it with water instead of a nutrient-rich broth or thickener, contrary to facility guidelines. The Dietary Manager was unaware of this deviation until after the food was served. The cook, filling in from another facility, admitted to forgetting the proper procedure due to nervousness, which led to a reduction in the food's nutritional value.
A resident on a no salt added diet was repeatedly given salt packets with meals, despite dietary orders and meal tickets indicating otherwise. Staff interviews revealed inconsistencies in checking meal trays for compliance with dietary orders, with the dietary aide missing the no salt instruction and the MDS nurse not checking the tray on the day of the incident.
Failure to Ensure Proper Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to ensure proper hand hygiene was practiced by dietary staff during food preparation and distribution. Observations revealed that one dietary staff member, after touching a disinfectant dish cloth and wiping a food prep table, did not wash or sanitize his hands before proceeding to handle food and food containers. He placed his fingers inside a silver container and then transferred pureed hashbrowns into it without performing hand hygiene. Another dietary aide was observed touching her clothing and then placing her fingers inside multiple cups and meal trays without washing or sanitizing her hands. Both staff members were not wearing gloves during these activities. Interviews with the involved staff confirmed that they were aware of the expectation to wash hands after touching contaminated items such as clothing or cleaning cloths, and acknowledged the possibility of transferring germs to food or food contact surfaces. The facility's policy, consistent with the 2017 Food Code, requires handwashing with soap and water in the kitchen after touching contaminated items or between tasks. The dietary manager and district director of operations both stated that staff are required to wash hands between tasks and after contact with contaminated surfaces, but the observed staff did not follow these procedures.
Improper Disposal of Garbage in Kitchen Area
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of garbage and refuse in the kitchen area. Specifically, a kitchen utility cart with an attached garbage can was found overflowing and uncovered, positioned near clean dishes and a food preparation area. The garbage can was approximately 2-3 feet from the food prep table where food was present, and clean cups were located nearby. The garbage remained in this state for at least 10 minutes during the observation, and no dietary staff were actively using the garbage container at that time. Multiple staff interviews revealed inconsistent understanding and practices regarding garbage disposal, with some staff acknowledging that garbage should be covered and kept out of the kitchen, while others, including the District Director of Operations and Dietary Manager, stated that uncovered garbage containers were allowed in the kitchen and did not require lids. The facility's own policy, revised in September 2021, requires that all trash be contained in leak-proof containers and covered during meal service to prevent cross-contamination. Despite this, staff interviews indicated that in-service training on garbage disposal had occurred, but staff could not recall specific dates or details. The Interim Administrator stated that garbage should not be near food prep areas or the stove, and acknowledged the potential for attracting flies if garbage was overflowing near food. However, the Dietary Manager and District Director of Operations did not consider the presence of uncovered, overflowing garbage in the kitchen to be an issue, and did not respond to questions about the potential for unsanitary conditions or negative outcomes.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance observed during surveyor review. During the morning medication pass, a medication aide did not clean the blood pressure cuff before or after use on three different residents, despite being aware of the requirement to disinfect equipment between residents. The aide acknowledged the lapse and confirmed knowledge of the facility's policy, which mandates cleaning with approved disinfectant wipes between each use to prevent cross-contamination. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound during wound care. Two nurses performed wound care without wearing gowns, and one nurse's uniform came into contact with the resident's bedding. There was no signage indicating the need for EBP on the resident's door at the time of care. Both nurses later acknowledged that gowns should have been worn and that failure to do so could result in cross-contamination. Interviews with facility leadership, including the ADON, DON, and administrator, confirmed that equipment should be disinfected between residents and that EBP should be used for residents with wounds or indwelling devices during high-contact care activities. The infection control preventionist admitted uncertainty regarding EBP implementation and only placed appropriate signage after the surveyor's observation. Facility policy and CDC guidance provided to surveyors supported the need for these infection control measures.
Failure to Update Care Plan with Oxygen Order
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident with multiple chronic conditions was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan did not reflect a current physician's order for oxygen to be administered as needed for shortness of breath or to maintain oxygen saturation above 92%. Despite the presence of this order, the intervention for oxygen as needed was not included in the resident's care plan or in the electronic records accessed by CNAs. Interviews with staff revealed that the omission of the oxygen order from the care plan led to a lack of awareness among CNAs regarding the resident's need for oxygen therapy. The CNAs relied on the electronic care plan for guidance on resident care and did not have access to physician's orders or other medical records. As a result, the CNAs were unaware that the resident required oxygen as needed, and this information was not available in their workflow. The MDS Coordinator and Director of Nurses both acknowledged that the care plan should have been updated to include the oxygen order. The facility's policy required care plans to be revised at regular intervals and when there was a change in a resident's health status. The failure to update the care plan with the current oxygen order placed the resident at risk of not receiving appropriate care and services to maintain her well-being.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with acute respiratory failure and hypercapnia, who was dependent on staff for all activities of daily living and required continuous oxygen therapy per physician order, was left without her oxygen concentrator for an extended period. The resident's care plan and physician orders specified continuous oxygen via nasal cannula at 2-4 L/min, and the facility's policy required oxygen to be administered according to provider orders and standards of practice. However, during a transfer from wheelchair to bed, the oxygen concentrator was left in a common area and not returned to the resident's room until after she was already in bed. Multiple staff interviews revealed a lack of clear communication and responsibility regarding the transfer and reapplication of the oxygen concentrator. The CNA responsible for the transfer stated that the resident was without oxygen for approximately 20 minutes, and neither the LPN nor the RN at the nurse's desk assisted or ensured the oxygen was reapplied promptly. The resident was observed lying in bed without oxygen, displaying a sad expression and being non-responsive to questions. Staff confirmed that the resident was supposed to have continuous oxygen and acknowledged the potential for hypoxia if oxygen was not provided as ordered. Documentation showed that after the lapse, the resident's oxygen was reapplied, and her vital signs and oxygen saturation were within normal limits. However, the incident demonstrated a failure to provide safe and appropriate respiratory care consistent with professional standards and physician orders. Staff interviews also indicated a lack of recent in-service training on oxygen care and protocol, contributing to the deficiency.
Expired Medication Found in Storage Room
Penalty
Summary
A deficiency was identified when a bottle of Aspirin 325 mg with an expiration date of 4/2025 was found in the medication storage room during an observation. The presence of this expired medication indicated that procedures for removing outdated drugs from inventory were not followed as required by facility policy. Interviews with staff revealed uncertainty regarding responsibility for checking and removing expired medications from the storage room, with both the RN and DON providing differing accounts of who was tasked with this duty. The DON stated she typically checked for expired medications on Monday mornings, while the weekend night medication aide was also said to be responsible for checking the carts and storage room. Further review of the facility's policy confirmed that outdated medications are to be removed from inventory and disposed of according to established procedures. The ADM acknowledged that expired medications should not be present in the storage room and indicated that nursing leadership was responsible for ensuring compliance. The failure to remove the expired Aspirin from the medication storage room constituted a lapse in the facility's pharmaceutical services and medication management procedures.
Failure to Maintain Proper Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in the kitchen, as observed during a survey. Specifically, an employee, identified as CK F, did not sanitize or wash her hands between tasks, such as after handling a puree blender from the dishwasher and after taking hamburger meat out of the oven. CK F also failed to change gloves after touching potentially contaminated surfaces, such as the recipe manual and oven door, before continuing food preparation tasks. These actions were observed on two separate occasions, indicating a pattern of non-compliance with hand hygiene protocols. Interviews with the Corporate Dietary Manager and the Dietary Manager confirmed that staff were expected to change gloves and wash hands between tasks to prevent cross-contamination. The Dietary Manager acknowledged that failing to follow these procedures could put residents at risk of illness. The Administrator also confirmed that hand hygiene training was conducted monthly, emphasizing the importance of washing hands for at least 20 seconds and changing gloves as necessary. Despite these training efforts, the observed deficiencies in hand hygiene practices were not in line with the facility's policies and procedures, as outlined in their Food Preparation Policy and Hand Hygiene Steps.
Lack of Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for residents' monthly council meetings, which is a violation of the residents' rights to organize and participate in resident/family groups. The meetings were held in the dining room, where interruptions by staff were frequent, despite attempts by the Activity Director to prevent them. The Activity Director acknowledged the lack of a private meeting space and mentioned that signs were placed on the privacy curtain to deter staff from entering during meetings. However, these measures were ineffective, and residents expressed dissatisfaction with the lack of privacy and respect during their meetings. Interviews with residents revealed that they felt disrespected by the interruptions and had previously informed the Administrator about the issue, but it persisted. The Administrator admitted that the facility was small and lacked sufficient space for private meetings, but acknowledged the residents' right to meet privately. The Resident Council Policy, dated 5/1/2012, states that it is the responsibility of the Activity Director/Social Services Designee to provide a private meeting space, which was not fulfilled in this case.
Deficiencies in Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal hygiene and grooming. Resident #26, a female with cerebral infarction and aphasia, was observed with 3-4 inches of facial hair, which had not been removed despite family requests. The resident was dependent on staff for ADLs, and her care plan indicated the need for assistance with personal hygiene. Resident #32, a male with hemiplegia, diabetes, and moderate cognitive impairment, had untrimmed and dirty fingernails with a blackish/brownish substance underneath. Despite requesting assistance, his nails remained uncleaned and untrimmed, posing a risk of infection, as he had previously experienced an infection from self-care attempts. His care plan required supervision and assistance with personal hygiene, including specific instructions for nail care due to his diabetes. Resident #140, a female with lymphedema and hypertension, also had long, dirty fingernails with a blackish substance underneath. She expressed embarrassment and had requested assistance, but her nails remained unaddressed. The facility's staff, including CNAs and nurses, were responsible for nail care and facial hair removal, but failed to provide timely and adequate care, as confirmed by interviews with staff and the facility's policies.
Inadequate Hand Hygiene Practices During Dining Services
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by staff not adhering to hand hygiene procedures during dining services. Specifically, a Speech Therapist and a Certified Nursing Assistant (CNA) were observed not sanitizing or washing their hands after touching potentially contaminated items before handling residents' food. This lapse in protocol was noted during the care of three residents, placing them at risk of food contamination. Resident #10, a male with multiple health issues including atrial fibrillation, cognitive communication defect, and type 2 diabetes, was involved in an incident where the Speech Therapist wiped her nose with her hand and then touched the resident's fruit cocktail without washing her hands. Similarly, Resident #26, a female with dementia and a history of COVID-19, and Resident #30, a female with dementia and chronic constipation, were involved in incidents where CNA G touched various surfaces and her clothing without sanitizing her hands before handling their food. Interviews with the involved staff revealed that both the Speech Therapist and CNA G were aware of the hand hygiene protocols but failed to adhere to them in practice. The facility's Administrator confirmed that all staff had been trained on hand hygiene, which is covered monthly, and emphasized the importance of following these protocols to prevent the spread of infections. The facility's policies on standard precautions and hand hygiene were reviewed, highlighting the requirement for hand hygiene before and after resident contact and after glove removal.
Improper Preparation of Pureed Hamburger Meat
Penalty
Summary
The facility failed to prepare pureed food by methods that conserve nutritive value, flavor, and appearance, as evidenced by the improper preparation of pureed hamburger meat. During an observation, it was noted that a cook, identified as CK F, mixed the hamburger meat with water instead of using a thickener or nutrient-rich broth. This practice was contrary to the facility's guidelines, which require staff to follow specific recipes for pureed diets to ensure the food retains its nutritional value. The Dietary Manager, responsible for overseeing the kitchen's pureed food preparation, was unaware of the deviation from the standard procedure until after the food had been served. Interviews revealed that CK F was filling in from another facility and had been trained on pureed diets, typically using broth, orange juice, or milk for mixing. However, CK F admitted to becoming nervous and forgetting the proper procedure, resulting in the use of water, which diminishes the food's nutritional content. The Dietary Manager acknowledged the oversight and stated that if she had known CK F was unfamiliar with the correct process, she would have intervened. The incident highlights a lapse in ensuring that staff adhere to established protocols for preparing pureed diets, potentially affecting residents' nutritional intake.
Failure to Provide Physician-Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide the physician-prescribed therapeutic diet to a resident who was on a no salt added diet. Despite the dietary orders and meal ticket indicating a no salt added diet, the resident was given salt packets with her meals on multiple occasions. The resident was aware of her dietary restrictions and reported that she did not use the salt, although it was provided to her regularly. This oversight was observed during both lunch and breakfast meal services. Interviews with various staff members, including dietary aides, the Dietary Supervisor, nurses, the DON, and the MDS nurse, revealed a lack of consistent checking and verification of meal trays to ensure compliance with dietary orders. The dietary aide responsible for placing condiments on trays admitted to missing the no salt instruction on the meal ticket. The Dietary Supervisor and nursing staff acknowledged that trays should be checked before being served to residents, but there was uncertainty and inconsistency in who was responsible for this task. The MDS nurse confirmed that she did not check the resident's tray on the day of the incident, highlighting a gap in the process of ensuring residents receive the correct diet.
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 126 citations issued within 25 miles in the last 12 months — including the 5 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 Luling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Magnolia | 2 mi | ★★★★★ | 21 | 2 |
| Avir At Luling | 2.2 mi | ★★★★★ | 17 | 0 |
| Parkview Nursing And Rehabilitation Center | 13.7 mi | ★★★★★ | 8 | 3 |
| Chisolm Trail Nursing And Rehabilitation Center | 14.9 mi | ★★★★★ | 1 | 0 |
| The Heights Of Gonzales | 15 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Diversicare Of Luling.
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 August 2026) and official state health department websites.