Cycle 1
Health 2025-05-08 · Fire 2025-05-08
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Luling, TX
Diversicare Of Luling
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
208 Maple St, Luling, TX
(830) 875-5219
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Diversicare Healthcare
Operator or chain grouping
Approved since
1992-08-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.97
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.62
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,711
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.79
Baseline 51.43% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 3.8
Adjusted total nurse staffing
0
Baseline 4.25 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 34 · Observed rate 11.76% · Lower 95% interval 7.39% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 16.67% |
8.2%
8.5 pts better
|
Numerator 6 · Denominator 36 |
| Staff flu vaccination coverage | 39.13% |
42%
2.9 pts worse
|
Numerator 18 · Denominator 46 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.3%
2.6 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.3% · Q3 2.6% · Q4 10.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
2.7%
1.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 2.8% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
3.3%
0.7 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 10.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
18.9%
5.7 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.0% · Q3 12.5% · Q4 19.4% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.9% |
10.8%
9.9 pts better
|
16.7%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.7% |
15.4%
4.3 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
16.1%
3.9 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 10.3% · Q3 10.0% · Q4 46.7% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.2% |
15.0%
3.8 pts better
|
19.8%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 17.4% · Q3 9.9% · Q4 9.8% · 4Q avg 11.2% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.2%
1.9 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.3% · Q3 5.9% · Q4 11.4% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
89.7%
6.7 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 96.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-05-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-09
E · Potential for more than minimal harm
2023-01-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-29
C · Minimal harm
2023-01-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-05-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-05-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-05-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-05-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-09
F · Potential for more than minimal harm
2024-03-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-03-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-03-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-03-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-21
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-04-22
E · Potential for more than minimal harm
2023-11-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-14
Penalties and ownership
What sits behind the stars
$0
2023-05-31
Payment Denial
Payment Denial · denial start 2023-08-31 · 29 days
29 day denial
Ownership
Dewitt Medical District
5% Or Greater Direct Ownership Interest · Organization
Frels, John
Corporate Director · Individual
Papacek, Charles
Corporate Director · Individual
Papacek, Charles
Corporate Officer · Individual
Pritchett, Gregory
Corporate Officer · Individual
Sheppard, Cynthia
Corporate Director · Individual
Sheppard, Cynthia
Corporate Officer · Individual
Stakes, Harry
Corporate Director · Individual
Weishaar, Matthew
Corporate Officer · Individual
Wheeler, Richard
Corporate Director · Individual
Wheeler, Richard
Corporate Officer · Individual
Williamson, Amber
W-2 Managing Employee · Individual
Nearby options
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#2
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#3
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