LAKESHORE VILLAGE NURSING AND REHABILITATION Inspection Report, Violations & Safety Grade (WACO, Texas)

2320 LAKE SHORE DR, WACO, Texas 76708

Phone: 2547521075

CMS Overall:1/5

Overview & Bed Count

Certified Beds

151

Avg Residents/Day

120.3

Ownership

Government - Hospital district

Provider Type

Medicare and Medicaid

County

Mc Lennan

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing2/5

Quality4/5

Nurse Staffing Check

Metric	This Facility	Texas Avg	Difference
RN Hours per Resident per Day	0.40	0.44	-0.04
Total Nurse Hours per Resident per Day	3.31	3.42	-0.10
CMS Staffing Rating	2/5	1.9/5	-
Nursing Staff Turnover	52.6%	50.8%	-

Health Citation History

53 health citations on record

Date	Category	Description	Severity
2026-08-21	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2026-04-22	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	E – Moderate Harm Potential
2026-04-22	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-04-22	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-04-22	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	D – Moderate Harm Potential
2026-03-03	Resident Rights Deficiencies	Provide immediate access to any resident.	F – Moderate Harm Potential
2025-12-11	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-05-10	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	J – Immediate Jeopardy
2025-05-10	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	J – Immediate Jeopardy
2025-02-20	Nutrition and Dietary Deficiencies	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.	F – Moderate Harm Potential
2025-02-20	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2025-02-20	Resident Rights Deficiencies	Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.	E – Moderate Harm Potential
2025-02-20	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	E – Moderate Harm Potential
2025-02-20	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	E – Moderate Harm Potential
2025-02-20	Nutrition and Dietary Deficiencies	Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	E – Moderate Harm Potential
2025-02-20	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2024-09-10	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2024-08-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	D – Moderate Harm Potential
2024-08-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2024-06-29	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2024-05-16	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2023-12-16	Administration Deficiencies	Administer the facility in a manner that enables it to use its resources effectively and efficiently.	L – Immediate Jeopardy
2023-12-16	Nursing and Physician Services Deficiencies	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.	K – Immediate Jeopardy
2023-12-16	Administration Deficiencies	Provide timely, quality laboratory services/tests to meet the needs of residents.	K – Immediate Jeopardy
2023-12-16	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	K – Immediate Jeopardy
2023-12-16	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	G – Actual Harm
2023-12-16	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-12-16	Administration Deficiencies	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	F – Moderate Harm Potential
2023-12-16	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	E – Moderate Harm Potential
2023-12-16	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2023-12-16	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2023-12-16	Quality of Life and Care Deficiencies	Provide activities to meet all resident's needs.	E – Moderate Harm Potential
2023-12-16	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	E – Moderate Harm Potential
2023-12-16	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2023-12-16	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2023-12-16	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2023-12-16	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2023-12-16	Environmental Deficiencies	Have policies on smoking.	E – Moderate Harm Potential
2023-12-16	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2023-12-16	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2023-12-16	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2023-12-16	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2023-12-16	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2023-12-16	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	D – Moderate Harm Potential
2023-12-16	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2023-12-16	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2023-12-16	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2023-12-16	Quality of Life and Care Deficiencies	Provide care or services that was trauma informed and/or culturally competent.	D – Moderate Harm Potential
2023-12-16	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	D – Moderate Harm Potential
2023-12-16	Quality of Life and Care Deficiencies	Provide or obtain dental services for each resident.	D – Moderate Harm Potential

Showing 50 of 53 citations.

Fire Safety Citation History

0 fire safety citations on record

No fire safety citations on record.

Total Penalties & Fines

$107,407

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-05-10	Fine	$23,593	-
2023-12-16	Fine	$83,814	-

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