Nursing home in Lewisville, Texas
Lake Village Nursing and Rehabilitation Center
Medicare and Medicaid
169 LAKE PARK RD, Lewisville, TX 75057
(972) 436-7571
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 home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- 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): May 5, 2026. CMS counts 12 health deficiencies in rating cycle 1.
- This nursing home12
- 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 33 health deficiencies on 6 inspection dates since Sep 30, 2023. By level of harm: 1 immediate jeopardy, 32 potential for harm.
- 1 Immediate jeopardy to resident health or safety
- 0 Actual harm
- 32 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 |
|---|---|---|---|---|---|
| May 5, 2026 | F0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Administration Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction May 8, 2026 |
| May 5, 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 8, 2026 |
| May 5, 2026 | F0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Environmental Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction May 8, 2026 |
| May 5, 2026 | 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 | Standard | Deficient, Provider has date of correction May 8, 2026 |
| May 5, 2026 | 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 | Deficient, Provider has date of correction May 8, 2026 |
| May 5, 2026 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction May 8, 2026 |
| May 5, 2026 | 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 | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction May 8, 2026 |
| May 5, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction May 8, 2026 |
| Nov 28, 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Past Non-Compliance |
| Nov 28, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Past Non-Compliance |
Show the other 23 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Sep 16, 2025 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Oct 15, 2025 |
| Sep 16, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Oct 15, 2025 |
| Mar 6, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Apr 4, 2025 |
| Mar 6, 2025 | 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 Apr 4, 2025 |
| Mar 6, 2025 | F0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 4, 2025 |
| Mar 6, 2025 | 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 | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 4, 2025 |
| Mar 6, 2025 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 4, 2025 |
| Mar 6, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 4, 2025 |
| Mar 6, 2025 | 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 | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Apr 4, 2025 |
| Dec 4, 2024 | 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 | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 31, 2024 |
| Dec 4, 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 Dec 31, 2024 |
| Jan 26, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | K Immediate jeopardy, pattern | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | F0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician Services Deficiencies | F Potential for harm, widespread | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | 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 | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 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 | Standard | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | 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 Feb 28, 2024 |
| Jan 26, 2024 | F0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | 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 | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | 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 | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
| Jan 26, 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 28, 2024 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.07 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 home0.44 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.[27]
- This nursing homeNot available
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 2 penalties for this nursing home: 1 fine totaling $24,585, and 1 payment denial. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 112 |
|---|---|
| Average residents per day | 76.5 |
| Ownership | For profit - Corporation |
| 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 | The Ensign Group (344 facilities) |
| Legal business name | EASTLAND MEMORIAL HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Jan 4, 1996 |
| County | Denton |
| CMS certification number | 675560 |
Also in Lewisville
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Vista Ridge Nursing & Rehabilitation Center | 132 | Government - Hospital district |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Medical City Lewisville | Acute Care Hospitals | Yes |
CMS footnotes on this page
- [27]
- This facility submitted staffing data that did not meet the criteria required to calculate a turnover measure. This measure will be excluded from the staffing rating and the staffing score will be rescaled.