Nursing homeActive
Lakeshore Village Nursing And Rehabilitation
2320 Lake Shore Dr, Waco, TX 767082547521075151 certified beds · 119 residentsGovernment - Hospital districtMedicare and Medicaid
Surveys on file
10
since 2023
Deficiencies
52
● 0● 45● 7
Penalties · 3 yrs
$107,407
2 fines
Last survey
2026-04-22
Standard
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 2
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-04-22 | Standard | 040 | CMS-2567 (Care Compare) | — |
| 2026-03-03 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-12-11 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-05-10 | Complaint | 002 | CMS-2567 (Care Compare) | — |
| 2025-02-20 | Standard | 070 | CMS-2567 (Care Compare) | — |
| 2024-09-10 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-08-21 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-06-29 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-05-16 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-12-16 | Standard | 0275 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-04Record 675438-20260422-F644
F732Post nurse staffing information every day.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-04Record 675438-20260422-F732
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-04Record 675438-20260422-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-04Record 675438-20260422-F880
F562Provide immediate access to any resident.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-03-04Record 675438-20260303-F562
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 675438-20251211-F689
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity JHarm
Dignity & rights
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-05-11Record 675438-20250510-F580
F692Provide enough food/fluids to maintain a resident's health.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-05-11Record 675438-20250510-F692
F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-14Record 675438-20250220-F557
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-14Record 675438-20250220-F558
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-14Record 675438-20250220-F561
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-14Record 675438-20250220-F677
F803Ensure 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.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-03-14Record 675438-20250220-F803
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-14Record 675438-20250220-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-03-14Record 675438-20250220-F812
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-11Record 675438-20240910-F761
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-05Record 675438-20240821-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-05Record 675438-20240821-F609
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-30Record 675438-20240629-F812
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-10Record 675438-20240516-F755
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-01-12Record 675438-20231216-F686
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity KHarm
Staffing
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-01-12Record 675438-20231216-F726
F770Provide timely, quality laboratory services/tests to meet the needs of residents.Scope/severity KHarm
Records
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-01-12Record 675438-20231216-F770
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity LHarm
Records
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-01-12Record 675438-20231216-F835
F880Provide and implement an infection prevention and control program.Scope/severity KHarm
Infection control
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-01-12Record 675438-20231216-F880
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F550
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F558
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F578
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F584
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F585
F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F640
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F677
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F679
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F695
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F699
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F759
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F761
F791Provide or obtain dental services for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F791
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F804
F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F810
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F812
F838Conduct 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.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F838
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F849
F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyScope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F868
F926Have policies on smoking.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-12Record 675438-20231216-F926
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-05-10 | Civil money penalty | $23,593 | CMS · Penalties |
| 2023-12-16 | Civil money penalty | $83,814 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.36
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day3.19
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours2.70
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover52%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover38%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 5.2% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.7% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 5.2% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 2.2% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 14.2% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 4.7% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 19.2% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Fannin County Hospital Authority Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Sanderson, Clark Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Bewsey, Michael Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sheddy, Theresa Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Waco Nursing And Rehab Center LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sanderson, Clark Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Sheddy, Theresa Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
Part of a chain
Eduro Healthcare — 34 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Mc Lennan.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Crestview Healthcare Residence Waco | 0.7 mi | 2025-08-14 | 0130 |
| Ivy Creek Wellness & Rehabilitation Waco | 2.7 mi | 2026-07-01 | 0143 |
| The Atrium of Bellmead Bellmead | 3.1 mi | 2026-06-18 | 061 |
| Woodland Springs Nursing Center Waco | 3.5 mi | 2026-03-02 | 0188 |
| Avir at Jeffrey Place Waco | 4.5 mi | 2026-04-09 | 0312 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |