Nursing home in Waco, Texas
Lakeshore Village Nursing and Rehabilitation
Medicare and Medicaid
2320 LAKE SHORE DR, Waco, TX 76708
(254) 752-1075
CMS star ratings
CMS gives this nursing home an overall star rating of 1 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home1
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home1
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home2
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home4
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Apr 22, 2026. CMS counts 6 health deficiencies in rating cycle 1.
- This nursing home6
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 52 health deficiencies on 10 inspection dates since Sep 30, 2023. By level of harm: 6 immediate jeopardy, 1 actual harm, 45 potential for harm.
- 6 Immediate jeopardy to resident health or safety
- 1 Actual harm
- 45 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Apr 22, 2026 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction May 4, 2026 |
| Apr 22, 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction May 4, 2026 |
| Apr 22, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction May 4, 2026 |
| Apr 22, 2026 | F0732 | Post nurse staffing information every day.Nursing and Physician Services Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction May 4, 2026 |
| Mar 3, 2026 | F0562 | Provide immediate access to any resident.Resident Rights Deficiencies | F Potential for harm, widespread | Complaint | Deficient, Provider has date of correction Mar 4, 2026 |
| Dec 11, 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| May 10, 2025 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident Rights Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction May 11, 2025 |
| May 10, 2025 | F0692 | Provide enough food/fluids to maintain a resident's health.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction May 11, 2025 |
| Feb 20, 2025 | F0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and Dietary Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction Mar 14, 2025 |
| Feb 20, 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | F Potential for harm, widespread | Standard, Complaint | Deficient, Provider has date of correction Mar 14, 2025 |
Show the other 42 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Feb 20, 2025 | F0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident Rights Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Mar 14, 2025 |
| Feb 20, 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Mar 14, 2025 |
| Feb 20, 2025 | F0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Mar 14, 2025 |
| Feb 20, 2025 | F0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Mar 14, 2025 |
| Feb 20, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Mar 14, 2025 |
| Sep 10, 2024 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Sep 11, 2024 |
| Aug 21, 2024 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 21, 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Jun 29, 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jun 30, 2024 |
| May 16, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jun 10, 2024 |
| Dec 16, 2023 | F0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently.Administration Deficiencies | L Immediate jeopardy, widespread | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician Services Deficiencies | K Immediate jeopardy, pattern | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0770 | Provide timely, quality laboratory services/tests to meet the needs of residents.Administration Deficiencies | K Immediate jeopardy, pattern | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | K Immediate jeopardy, pattern | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies | G Actual harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | F Potential for harm, widespread | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministration Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0679 | Provide activities to meet all resident's needs.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0926 | Have policies on smoking.Environmental Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0584 | 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.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0699 | Provide care or services that was trauma informed and/or culturally competent.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0791 | Provide or obtain dental services for each resident.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and Dietary Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Administration Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
| Dec 16, 2023 | F0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Administration Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jan 12, 2024 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.19 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.36 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home52.1%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 2 penalties for this nursing home: 2 fines totaling $107,407, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 151 |
|---|---|
| Average residents per day | 118.8 |
| Ownership | Government - Hospital district |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | Eduro Healthcare (34 facilities) |
| Legal business name | FANNIN COUNTY HOSPITAL AUTHORITY |
| First approved for Medicare and Medicaid | Dec 22, 1994 |
| County | Mc Lennan |
| CMS certification number | 675438 |
Also in Waco
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|---|---|---|---|---|
| St. Catherine Center | 165 | Non profit - Corporation | ||
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| Crestview Healthcare Residence | 192 | For profit - Limited Liability company | ||
| St. Anthony's Care Center | 120 | For profit - Individual | ||
| Avir at Jeffrey Place | 95 | For profit - Limited Liability company | ||
| Wesley Woods Health & Rehabilitation | 120 | For profit - Corporation | ||
| Woodway Rehabilitation and Healthcare Center | 144 | For profit - Corporation | ||
| Greenview Nursing and Rehabilitation | 128 | For profit - Corporation | ||
| Ivy Creek Wellness & Rehabilitation | 162 | For profit - Corporation | ||
| Ridgecrest Retirement and Healthcare Community | 90 | For profit - Limited Liability company | ||
| The Chateau Waco | 123 | Government - Hospital district | ||
| Woodland Springs Nursing Center | 132 | For profit - Corporation |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Baylor Scott & White Medical Center Hillcrest | Acute Care Hospitals | Yes | |
| Ascension Providence | Acute Care Hospitals | Yes | |
| Oceans Behavioral Hospital of Waco | Not available | Psychiatric | No |