Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Luling Living Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a clearly documented full code status was found unresponsive, pulseless, and not breathing. Staff policy and American Heart Association guidelines required immediate, continuous CPR until advanced medical providers arrived, but video review and interviews showed that no CPR equipment was brought to the room and no continuous CPR was provided. An LPN assumed the resident was DNR because hospice services were in place and did not verify code status, while another LPN acknowledged not initiating CPR until instructed by the DON. The hospice nurse arrived to find the resident covered with no life-saving measures in progress, despite existing orders for full code, and the facility could not produce evidence that the resident’s code status was promptly verified or that CPR was continuously performed.
The facility failed to ensure that a resident with a physician’s order for full code status received timely and continuous CPR when found unresponsive, as nursing staff did not accurately verify the resident’s code status and did not maintain resuscitation efforts until EMS arrival, and facility leadership did not initially recognize or investigate this as deficient practice or provide staff re-education on CPR and code status verification. In addition, when no Treatment Nurse was on duty, multiple residents with Stage III and Stage IV pressure ulcers did not receive ordered wound care because LPNs were not clearly informed they were responsible for performing wound treatments on their assigned residents, despite the expectation by the DON and RN Supervisor that floor nurses would assume this role.
The facility failed to provide physician-ordered daily wound care for three residents with Stage II–IV pressure ulcers to the sacrum and heel. Each resident had specific orders for daily cleansing, application of Santyl and/or Collagenase, use of calcium alginate, and coverage with silicone foam border dressings, with changes every day and as needed. Treatment records showed that ordered wound care was not completed on multiple consecutive days, and dressings observed in place were dated several days earlier. The treatment nurse, LPNs assigned on those days, the DON, and a contracted wound care NP all acknowledged that the daily pressure ulcer treatments were not performed as ordered.
The facility failed to maintain complete and accurate clinical records for multiple residents, including missing documentation on MARs for ordered medications such as antidepressants, anticoagulants, antibiotics, and sleep aids, and missing entries on TARs for ordered wound care, low air loss mattress use, and pain assessments. ADL records also lacked required charting of bed mobility, toileting, transfers, and other self-care assistance for several residents whose care plans and assessments showed they required staff help. The DON, CNA Supervisor, and a contracted wound care nurse all confirmed that these medications, treatments, and ADL services should have been documented, leaving the facility unable to verify that physician-ordered care was provided as required.
Missed Medication Administrations: A resident had multiple ordered medications omitted without documented reasons, including doses of Simethicone, Gabapentin, Meloxicam, Sertraline, and Pataday eye drops. An LPN believed one medication was out of stock but did not verify availability, while the DON and RN confirmed the medications were available and should have been given as ordered.
A resident with a broken lower molar and dental pain did not receive the planned follow-up dental care after a contracted dental cleaning. The dentist requested a triage form so the resident could be seen, but Social Services did not complete it in time for the scheduled dental visit, and the DON stated it should have been sent earlier.
A resident with an enteral tube had an active order for Diabetisource at 45 mL/hr with a 200 mL water flush every hour, but observations showed the pump was set to give a 150 mL water flush every 4 hours instead. An LPN confirmed the pump settings did not match the physician's order, and the DON acknowledged the ordered flush was not being administered as prescribed.
Failure to Coordinate Hospice Documentation: A resident admitted for hospice services did not have the required hospice binder at the facility, and staff could not provide the admission orders and hospice documentation expected to coordinate care. The DON, an LPN, the hospice agency's records representative, and the Administrator all confirmed the binder was missing and should have been available.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and indicated a failure to meet required standards for resident care.
Two residents did not have their medical records accurately documented, as LPNs recorded completion of suprapubic catheter care and use of a pressure relieving cushion without actually performing or verifying these tasks. The DON confirmed the inaccuracies, and the Administrator did not dispute the findings.
The facility did not ensure that direct care staff received effective communication training, as required. Personnel records for several CNAs showed no evidence of this training, and both the CNA Supervisor and DON confirmed that such training was not part of orientation or in-service programs.
The facility did not provide required QAPI training to several CNAs, as confirmed by personnel record reviews and staff interviews. The CNA Supervisor acknowledged that QAPI training was not part of orientation or in-service education, and the DON confirmed the deficiency.
The facility did not ensure its facility-wide assessment included input from direct care staff (RN, LPN, CNA), a resident, and resident representatives, nor did it document the current resident census. The administrator confirmed these omissions during the survey.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
For three consecutive days, the facility did not post complete nurse staffing information at the start of each shift, omitting both the daily census and the actual hours worked by RNs, LPNs, and CNAs. This deficiency was confirmed by the DON and the Administrator.
Failure to Provide CPR According to Full Code Status and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR, in accordance with a resident’s documented full code status and physician orders. The facility’s CPR policy required staff to provide basic life support prior to the arrival of emergency personnel, consistent with the resident’s physician orders and advance directives. The American Heart Association Basic Life Support Algorithm referenced in the report emphasized that high-quality CPR is the most critical part of basic life support and should continue until advanced medical providers arrive or the patient shows signs of life. For this resident, multiple documents, including a Louisiana Physician Orders for Scope of Treatment form, monthly physician orders, hospice certification and plan of care, and the comprehensive care plan, all indicated a full code status, requiring CPR if the resident was unresponsive, pulseless, and not breathing. On the day of the incident, the resident, who had diagnoses including hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease, and chronic obstructive pulmonary disease, was found unresponsive and not breathing. Surveillance footage showed that a CNA exited the resident’s room and quickly summoned the CNA supervisor, who then returned to the room and called for additional staff. Two LPNs entered the room shortly thereafter, but video review from the time the incident began until well after showed that no cardiopulmonary emergency equipment, such as a backboard, Ambu bag, or crash cart, was brought into the room. Documentation in a health status note by one of the LPNs stated that she was summoned to the room, found the resident unresponsive and not breathing, and that she attempted CPR but was unsuccessful, with the time of death later documented as pronounced by the hospice nurse. Interviews and video review, however, did not corroborate that CPR was initiated or continued as required. One LPN reported that when she assessed the resident, he had no pulse, was still warm, and showed no signs of prolonged death, but she did not discuss or verify the resident’s code status and assumed the resident was DNR because he was on hospice. She stated she was not aware the resident was full code and had not observed anyone performing CPR. The DON reported that the other LPN had initially believed the resident was DNR and admitted she had not yet implemented CPR; the DON then instructed her to return to the room and start CPR. The hospice nurse stated she was notified that the resident had expired and, upon arrival, found the resident in bed with a sheet over his head and no life-saving measures in progress. She was told that CPR had been started and stopped, but she did not instruct staff to stop CPR and expected it to continue until EMS or a physician directed otherwise. The facility was unable to provide evidence that any licensed nursing staff immediately verified the resident’s code status or ensured continuous CPR from the time the resident was found without a pulse and not breathing until the official time of death, resulting in an Immediate Jeopardy determination.
Removal Plan
- S5LPN was in-serviced on checking Code Status in the Electronic Medication Administration Record (EMAR) and proper procedures for CPR.
- All active residents' EMARs were reviewed to ensure code status was posted.
- All nurses for each shift were in-serviced for checking code status in the EMAR and proper procedures for CPR.
- Implemented a policy to train all nurses on checking code status in the EMAR and proper procedures for CPR prior to working on the floor.
- All new hire nurses will be trained on checking code status and proper procedures for CPR prior to working on the floor.
- Removed the code status binder and red dot stickers; they are no longer in use.
- Required that a resident's code status must be checked in the EMAR.
- The DON will monitor weekly to ensure proper training is provided to all nurses and completed prior to working on the floor.
- The DON will audit training documents prior to scheduling nurses to the floor on a weekly basis and before all new hires.
- The DON will not schedule any nurse who has not completed the required training.
Failure to Ensure CPR per Code Status and Wound Care Coverage in Absence of Treatment Nurse
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources to maintain residents’ highest practicable physical well-being, specifically in relation to CPR and code status verification. One resident with a physician’s order for full code status was found unresponsive, pulseless, and not breathing. Licensed nursing staff did not accurately determine this resident’s code status and failed to initiate and continuously provide CPR in accordance with the physician’s full code order until EMS arrived. When the hospice nurse arrived, no life-saving measures were in progress, and the resident was later pronounced deceased. The DON stated she had not identified this incident as deficient practice at the time it occurred and did not realize the magnitude of the problem until it was brought to her attention during the survey. The DON also acknowledged that the facility did not provide additional education to nursing staff on verifying code status and continuing CPR until EMS assumed responsibility. The facility’s administration, including the Administrator and DON, did not have an adequate system in place to identify this deficient practice, determine its root cause, or ensure that nursing staff were trained and competent in verifying residents’ code status and implementing CPR according to orders. The Administrator indicated that when it was discovered that the LPN had not properly determined the resident’s code status and had not continued CPR until EMS arrival, administrative staff should have reviewed the incident to determine the root cause and re-educated nursing staff on the CPR policy and procedure. However, this did not occur prior to the surveyors’ identification of the issue. As a result, the surveyors determined that an Immediate Jeopardy situation existed related to the failure to ensure CPR was initiated and continued for a resident with full code status. A second deficiency involved the facility’s failure to have an adequate system to ensure that licensed nursing staff were made aware of their responsibilities for wound care in the absence of a Treatment Nurse. Multiple residents with pressure ulcers did not receive wound care as ordered by their physicians on days when no Treatment Nurse was assigned. The Treatment Nurse stated that weekend nurses should perform wound care when a Treatment Nurse is not present. Several LPNs reported they did not provide ordered wound care to residents with Stage III and Stage IV pressure ulcers because they were not aware they were responsible for completing wound care on their assigned residents. The DON indicated that on specific dates without a Treatment Nurse, it was the RN Supervisor’s responsibility to remind floor nurses to complete wound care, and a communication sheet instructed the RN Supervisor to remind nurses to perform wound care and sign the Treatment Administration Record. The RN Supervisor stated it was an understood responsibility that floor nurses were responsible for wound care in the absence of a Treatment Nurse, but the interviewed LPNs’ statements showed they had not been effectively informed of this responsibility, resulting in missed wound treatments as ordered. Overall, the facility’s administrative systems did not ensure that critical clinical responsibilities—verifying and acting on residents’ code status with appropriate CPR, and providing ordered wound care in the absence of a Treatment Nurse—were clearly assigned, communicated, and carried out by nursing staff. The DON’s and Administrator’s own interviews confirmed that they had not identified the CPR incident as deficient practice at the time, had not conducted a root cause review, and had not re-educated staff on CPR procedures, and that the process for ensuring wound care coverage on days without a Treatment Nurse relied on informal understandings rather than a consistently implemented system, leading to missed treatments for residents with pressure ulcers.
Removal Plan
- In-service nurses on checking a resident's Code Status in the EMAR and proper procedures for CPR.
- Review all active residents' EMAR to ensure Code Status is posted.
- Identify residents with DNR status.
- In-service all nurses on each shift on checking Code Status in the EMAR and proper procedures for CPR.
- Update the policy and procedure for Review of Resident Deaths.
- Implement a Death Review form for the DON and/or Quality Nurse to complete and immediately initiate changes as needed.
- Require all resident deaths be reviewed by the DON/designee.
- Require unexpected/high-risk deaths be reviewed by the DON/designee.
- Require cases be presented to QAPI at the next scheduled meeting.
- Consult on the death review policy/procedure, how to complete the Death Review form, actions for discrepancies, training nurses to look up code status in the EMAR, and proper CPR procedure.
- QAPI Team to verify the DON is reviewing completed Death Review forms and following through on discrepancies.
- QAPI to monitor Death Review forms.
- QAPI to review all Death Review forms.
Failure to Provide Ordered Daily Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered daily pressure ulcer treatments for three residents with documented pressure injuries. The facility’s Wound Care Protocol required that residents with wounds receive wound care as ordered by the physician. Resident #7 had a care plan and physician’s orders for daily treatment of a Stage IV sacral pressure ulcer, including cleansing with wound cleanser, application of Dakin’s solution–soaked gauze, Santyl ointment, calcium alginate, and a silicone foam border dressing, with dressing changes daily and as needed. On observation, the sacral dressing was dated 03/20/2026, and the Treatment Administration Record (TAR) showed no documented wound care on 03/21/2026 and 03/22/2026. The treatment nurse and the LPNs assigned on those dates each confirmed that the ordered wound care was not provided. Resident #16 had a diagnosis of a Stage II sacral pressure ulcer with physician’s orders, dated 02/18/2026, for daily wound care. The ordered regimen included cleansing with wound cleaner, patting dry, applying Santyl ointment and calcium alginate, and applying Collagenase ointment to the sacral wound every day shift, with a silicone foam border dressing to be changed daily and as needed if soiled or dislodged. The resident’s care plan included an intervention to administer daily wound care as ordered. Review of the March 2026 TAR showed that the daily wound care was not completed on 03/21/2026 and 03/22/2026. On observation, the sacral dressing was dated 03/20/2026, and the treatment nurse, DON, contracted wound care nurse practitioner, and an LPN all acknowledged that the daily wound care ordered by the physician was not performed on those days. Resident #44 had a care plan and physician’s orders for daily treatment of a Stage III right heel pressure ulcer. The orders included cleansing the right heel pressure injury with wound cleanser, patting dry, applying Santyl ointment to the wound bed, covering with a silicone foam border or equivalent dressing, changing the dressing daily and as needed, and applying Collagenase ointment to the right heel every day shift. Review of the March 2026 TAR revealed that wound care to the right heel was not completed on 03/21/2026 and 03/22/2026. Observation showed the right heel dressing was dated 03/20/2026. The treatment nurse, DON, contracted wound care nurse practitioner, and the LPNs assigned on those dates each confirmed that the resident did not receive the ordered daily wound care to the Stage III right heel pressure ulcer on those days.
Failure to Maintain Complete and Accurate Medication, Treatment, and ADL Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, including medication administration, treatments, and activities of daily living (ADL) documentation, for multiple residents. Facility policies required that all medications administered, treatments performed, and services provided be documented in the clinical record. For one resident, physician orders for several medications, including mirtazapine, Seroquel, and ophthalmic solutions, were written to be administered on a specific evening, but the Medication Administration Record (MAR) contained no documentation that these medications were given. The DON confirmed that these medications should have been documented as administered and, in the absence of documentation, the facility could not verify administration. Another resident had physician orders for daily sacral pressure ulcer wound care, use of a low air loss mattress, and pain assessments prior to wound care, as well as a care plan indicating assistance was required for bed mobility, toileting, and transfers. The Treatment Administration Record (TAR) showed no documentation that wound care was provided on several dates, and there was no documentation that the low air loss mattress and pain assessments were provided on multiple dates. ADL documentation for this resident also lacked entries for bed mobility, toileting, and transfers on several days. A contracted wound care nurse stated that these treatments and pain assessments should have been documented as provided. For another resident who required total assistance with bed mobility, ADL records over a multi-day period lacked documentation of bed mobility assistance on numerous shifts; the CNA Supervisor and DON both acknowledged that this documentation was missing and should have been present. Additional residents were affected by similar documentation failures. One resident had multiple medications ordered, including atorvastatin, hydrocortisone suppositories, melatonin, trazodone, Xarelto, and buspirone, to be administered on specified evenings, but the MAR did not show that these medications were administered as ordered; the DON confirmed the lack of documentation. Another resident with orders for heel pressure ulcer wound care, a low air loss mattress, pain assessments prior to wound care, and staff assistance with ADLs had missing documentation on the TAR and ADL records for multiple dates, and both the CNA Supervisor and DON agreed that assistance and treatments should have been documented. A further resident had orders for gabapentin, latanoprost, melatonin, sertraline, and amoxicillin-clavulanate for administration on a specific evening, but the MAR lacked documentation of administration; the DON again confirmed that these medications should have been documented as given. Across all these cases, the facility was unable to verify that ordered medications, treatments, and ADL services were provided due to incomplete and inaccurate records.
Missed Medication Administrations
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident #47, based on record review and staff interviews. Physician orders in the resident’s chart included Simethicone 80 mg twice daily, Pataday ophthalmic solution 0.2% daily, Gabapentin 300 mg daily, Meloxicam 15 mg daily, and Sertraline HCl 25 mg daily. Review of the MAR showed multiple missed doses with blank entries and no documented reason, including missed doses of Simethicone, Gabapentin, Meloxicam, and Sertraline in January 2026, as well as missed doses of Pataday ophthalmic solution in March 2026. During interview, an LPN stated she believed the Pataday ophthalmic solution was out of stock, but she did not verify the location of available medication and did not administer it as ordered. The DON stated Simethicone and Pataday were stocked with the facility’s OTC medications and available for use. An RN also stated the non-OTC medications were delivered weekly from the pharmacy and verified the medications were available for administration. The DON later confirmed the medications were available, should have been administered as ordered, and were not.
Failure to Arrange Timely Dental Follow-Up
Penalty
Summary
The facility failed to ensure a resident received dental services as required. Resident #47 was seen by the facility’s contracted dental company for a broken lower left tooth, and the dentist’s plan was to complete a #18 distolingual silver modified atraumatic restorative technique (SMART) filling for the permanent lower left second molar. The resident reported that the broken tooth occurred during a contracted dental cleaning in the facility and that the hygienist told her the tooth would need to be filled at a follow-up appointment. The resident later complained of dental pain, and the Social Services Director emailed the contracted dentist. The dentist requested completion of a triage form so the resident could be seen, but the Social Services Director did not complete the form until more than a month later, which resulted in the resident not being seen during the scheduled dental visit. The DON stated the triage form should have been sent to the contracted dental company before that visit.
Incorrect Enteral Tube Hydration Programming
Penalty
Summary
Resident #4 had an active physician's order dated 03/17/2026 to receive Diabetisource at 45 milliliters per hour continuously with a water flush of 200 milliliters every hour through an enteral tube. During observations on 03/23/2026 and 03/24/2026, the resident's enteral feeding pump was instead set to deliver Diabetisource at 45 milliliters per hour continuously with a water flush of 150 milliliters every 4 hours. On 03/24/2026, an LPN confirmed the pump was programmed for the 150 milliliter every 4 hour flush and acknowledged that the active physician's order called for a 200 milliliter hourly flush. The DON also confirmed the pump was not programmed to administer the ordered 200 milliliter water flush and stated it should have been administered as ordered.
Failure to Coordinate Hospice Documentation
Penalty
Summary
The facility failed to coordinate hospice care and obtain required information from the resident's hospice agency for Resident #23, who was admitted to the facility on 08/18/2025 and admitted for hospice services on 02/24/2026. The facility's Hospice Program policy stated that when a resident participated in hospice, a coordinated plan of care between the facility, hospice agency, and resident/family would be developed and would include directives for managing pain and other uncomfortable symptoms. On the day of admission, the facility nurse was expected to obtain admission orders and a binder from the hospice nurse, but the facility did not have Resident #23's hospice binder. On 03/23/2026 and again on 03/24/2026, the surveyor requested the binder from the DON and then from an LPN, and the LPN stated the facility did not have one and should have. The hospice agency's medical records representative stated the binder should be created by the hospice agency and brought to the facility by the hospice nurse, and both the DON and the Administrator later acknowledged that the facility did not have the binder and should have had it available.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly linked to the facility's failure to meet required standards for resident care in these domains.
Inaccurate Documentation of Resident Care in Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two of three sampled residents. For one resident, a physician's order required suprapubic catheter care to be performed every shift. However, review of the electronic Medication Administration Record (eMAR) showed that an LPN documented the catheter care as completed, but later admitted in an interview that she did not perform the care during her shift as ordered. For another resident, physician's orders required both suprapubic catheter care every shift and the use of a pressure relieving cushion on the resident's wheelchair to prevent skin breakdown. The eMAR reflected that catheter care and the presence of the cushion were documented as completed by multiple LPNs on several shifts. However, observation revealed the resident was sitting in the wheelchair without the cushion, and the resident reported not having had a cushion in months. One LPN admitted to documenting catheter care and the presence of the cushion without verifying or performing these tasks. The Director of Nursing confirmed the documentation was inaccurate, and the Administrator did not dispute the findings.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide effective communication training to direct care staff members, as evidenced by record reviews and staff interviews. Personnel records for five certified nursing assistants (CNAs) showed that none had received the required effective communication training since their respective dates of hire. Interviews with the CNA Supervisor confirmed that effective communication training was not included in either new hire orientation or ongoing in-service training. The Director of Nursing also confirmed that these staff members had not received the necessary training.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all direct care staff as required. Record reviews showed that five sampled Certified Nursing Assistants (CNAs), each with documented hire dates in 2025, did not receive QAPI training. Interviews with the CNA Supervisor revealed that QAPI training was not included in either new hire orientation or ongoing in-service education. The Director of Nursing confirmed that these staff members had not received the required QAPI training.
Facility Assessment Lacked Required Input and Census Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that included active participation from direct care staff, such as a Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA), as well as a resident and resident representatives. The assessment also did not document the current number of residents in the facility at the time it was completed. These omissions were confirmed through review of the facility assessment and an interview with the administrator, who acknowledged that the required individuals were not involved in the assessment's development and that the average daily census was not included.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information at the beginning of each shift for three consecutive days. Observations on each of these days revealed that the posted nurse staffing information did not include the facility's daily census or the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). These omissions were confirmed during interviews with the Director of Nursing and the Administrator, who acknowledged that the staffing reports lacked the necessary details as required.
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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.
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Nursing homes near Luling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ormond Nursing & Care Center | 3.6 mi | — | 0 | 0 |
| Waldon Health Care Center | 9.6 mi | — | 6 | 0 |
| St Joseph Of Harahan | 9.7 mi | — | 3 | 0 |
| Chateau Living Center | 9.8 mi | — | 4 | 0 |
| Metairie Health Care Center | 11.2 mi | — | 7 | 0 |
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