Government - Hospital district · 151 certified beds · CMS number 675438
Lakeshore Village Nursing and Rehabilitation, Waco, TX
CMS records 52 health deficiencies at Lakeshore Village Nursing and Rehabilitation in Waco, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Apr 22, 2026. The highest severity cited is L (immediate jeopardy to resident health or safety). 6 citations were at the immediate jeopardy level. CMS lists 2 fines totaling $107,407 in the last three years.
- 52deficiencies, 3 cycles (TX median 25)
- 6in the latest cycle (TX median 8)
- Lhighest severity · Immediate jeopardy
- $107,407fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Lakeshore Village Nursing and Rehabilitation as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Lakeshore Village Nursing and Rehabilitation may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (6 deficiencies)
Standard inspection Apr 22, 2026. CMS counts 6 health deficiencies and 0 fire safety deficiencies in this cycle.
Apr 22, 2026 · Standard inspection
4 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 4, 2026
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 4, 2026
F732 · Daily posting of nurse staffing
Requirement cited (CMS): Post nurse staffing information every day.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 4, 2026
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 4, 2026
Mar 3, 2026 · Complaint inspection
1 deficiency, highest F
F562 · Access for officials and advocates
Requirement cited (CMS): Provide immediate access to any resident.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Mar 4, 2026
Dec 11, 2025 · Complaint inspection
1 deficiency, highest D
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 12, 2025
Previous cycle: 10 deficiencies (standard inspection Feb 20, 2025)
Standard inspection Feb 20, 2025. CMS counts 10 health deficiencies and 0 fire safety deficiencies in this cycle.
May 10, 2025 · Complaint inspection
2 deficiencies, highest J
F692 · Nutrition and hydration
Requirement cited (CMS): Provide enough food/fluids to maintain a resident's health.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date May 11, 2025
F580 · Telling residents and families about changes
Requirement cited (CMS): Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date May 11, 2025
Feb 20, 2025 · Standard + complaint inspection
7 deficiencies, highest F
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Mar 14, 2025
F806 · Allergies, preferences, and meal substitutes
Requirement cited (CMS): Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 14, 2025
F803 · Menus that meet nutritional needs
Requirement cited (CMS): 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.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Mar 14, 2025
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 14, 2025
F561 · Making everyday choices
Requirement cited (CMS): Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 14, 2025
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 14, 2025
F557 · Respect and personal belongings
Requirement cited (CMS): Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 14, 2025
Sep 10, 2024 · Complaint inspection
1 deficiency, highest E
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 11, 2024
Earlier cycle: 36 deficiencies (standard inspection Dec 16, 2023)
Standard inspection Dec 16, 2023. CMS counts 36 health deficiencies and 0 fire safety deficiencies in this cycle.
Aug 21, 2024 · Complaint inspection
2 deficiencies, highest D
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F607 · Abuse prevention policies
Requirement cited (CMS): Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
Jun 29, 2024 · Complaint inspection
1 deficiency, highest E
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 30, 2024
May 16, 2024 · Complaint inspection
1 deficiency, highest E
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 10, 2024
Dec 16, 2023 · Standard + complaint inspection
32 deficiencies, highest L
F926 · Smoking policies
Requirement cited (CMS): Have policies on smoking.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Jan 12, 2024
F868 · Quality committee membership and meetings
Requirement cited (CMS): Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Jan 12, 2024
F849 · Hospice services
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F838 · Facility-wide assessment of needs
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F835 · Effective administration
Requirement cited (CMS): Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- Severity
- L Immediate jeopardy to resident health or safety, widespread
- Status
- Correction date Jan 12, 2024
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Jan 12, 2024
F810 · Adaptive eating equipment and help
Requirement cited (CMS): Provide special eating equipment and utensils for residents who need them and appropriate assistance.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F804 · Palatable, attractive food at safe temperatures
Requirement cited (CMS): Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F791 · Dental services in Medicaid nursing facilities
Requirement cited (CMS): Provide or obtain dental services for each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F770 · Timely laboratory services
Requirement cited (CMS): Provide timely, quality laboratory services/tests to meet the needs of residents.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Jan 12, 2024
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F726 · Competent nurses and nurse aides
Requirement cited (CMS): 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.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Jan 12, 2024
F699 · Trauma-informed, culturally competent care
Requirement cited (CMS): Provide care or services that was trauma informed and/or culturally competent.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Correction date Jan 12, 2024
F679 · Activities program
Requirement cited (CMS): Provide activities to meet all resident's needs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F658 · Professional standards in care
Requirement cited (CMS): Ensure services provided by the nursing facility meet professional standards of quality.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 12, 2024
F640 · Submitting assessment data on time
Requirement cited (CMS): Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F585 · Grievances and how they are handled
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F578 · Refusing treatment and advance directives
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 12, 2024
Tags cited in more than one inspection
7 tags cited on more than one inspection date at Lakeshore Village Nursing and Rehabilitation; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F812 Food safety and sanitation | 4 | Apr 22, 2026; Feb 20, 2025; Jun 29, 2024; Dec 16, 2023 |
| F558 Accommodating individual needs and preferences | 2 | Feb 20, 2025; Dec 16, 2023 |
| F677 Help with daily care | 2 | Feb 20, 2025; Dec 16, 2023 |
| F689 Accident prevention and supervision | 2 | Dec 11, 2025; Dec 16, 2023 |
| F755 Pharmacy services and a consultant pharmacist | 2 | May 16, 2024; Dec 16, 2023 |
| F761 Drug labeling and secure storage | 2 | Sep 10, 2024; Dec 16, 2023 |
| F880 Infection prevention and control program | 2 | Apr 22, 2026; Dec 16, 2023 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| May 10, 2025 | Fine | $23,593 |
| Dec 16, 2023 | Fine | $83,814 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.19 h (about the same as the Texas median of 3.27 h)
- RN hours per resident per day
- 0.36 h (below the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.70 h
- Nursing staff turnover
- 52.1% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 1 of 5
- Health inspection rating
- 1 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- 4 of 5
CMS figures for Lakeshore Village Nursing and Rehabilitation, copied as published; Texas medians are ours.
Facility details
- Address
- 2320 Lake Shore Dr, Waco, TX 76708
- Phone
- (254) 752-1075
- County
- Mc Lennan
- Accepts
- Medicare and Medicaid
- Ownership
- Government - Hospital district
- Chain (CMS)
- Eduro Healthcare
- Certified beds
- 151
- Average residents per day
- 118.8
- In Medicare/Medicaid since
- Dec 22, 1994
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- When was the kitchen last inspected, and how are food temperatures checked? (F812, cited 4 times)
- How does the home adapt rooms and routines for residents with limited mobility, vision, or hearing? (F558, cited 2 times)
- How often do residents who need help get assistance with bathing, grooming, and mouth care? (F677, cited 2 times)
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 2 times)
Other nursing homes in Waco and the same chain
- Greenview Nursing and Rehabilitation
Waco · 53 deficiencies - Avir at Jeffrey Place
Waco · 33 deficiencies - The Chateau Waco
Waco · 31 deficiencies - Wesley Woods Health & Rehabilitation
Waco · 29 deficiencies - Woodland Springs Nursing Center
Waco · 29 deficiencies - Ridgecrest Retirement and Healthcare Community
Waco · 27 deficiencies - Richardson Nursing and Rehabilitation
Richardson · 63 deficiencies - Memorial Medical Nursing and Rehabilitation
San Antonio · 57 deficiencies - San Antonio North Nursing and Rehabilitation
San Antonio · 56 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.