Home › Texas › McLennan County › Lakeshore Village Nursing and Rehabilitation
Lakeshore Village Nursing and Rehabilitation
2320 Lake Shore Dr, Waco, TX 76708 · CMS Certification Number (CCN) 675438
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 52 in the last 3 inspection cycles (6 immediate jeopardy, 1 actual harm, 32 from complaints)
- Fire safety citations
- 0
- Fines (last 3 years)
- 2 fines, total $107,407
- Payment denials
- 0
- Most recent standard inspection
- April 22, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★☆☆☆☆ 1 of 5 | 2.8 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | April 22, 2026 | 6 | 4 | 2 |
| Cycle 2 | February 20, 2025 | 35 | 7 | 30 |
CMS weighted health inspection score: 186.75 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: 0. How to read these citations
52 health citations across 10 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
April 22, 2026: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/04/2026 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/04/2026 |
| D | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/04/2026 |
| E | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/04/2026 |
March 3, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0562 | Provide immediate access to any resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/04/2026 |
December 11, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/12/2025 |
May 10, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/11/2025 |
| J | F-0580 | 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 | Complaint | Deficient, Provider has date of correction Corrected 05/11/2025 |
February 20, 2025: 7 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/14/2025 |
| E | F-0806 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/14/2025 |
| F | F-0803 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/14/2025 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/14/2025 |
| E | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/14/2025 |
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/14/2025 |
| E | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/14/2025 |
September 10, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0761 | 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 | Complaint | Deficient, Provider has date of correction Corrected 09/11/2024 |
August 21, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/05/2024 |
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/05/2024 |
June 29, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/30/2024 |
May 16, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/10/2024 |
December 16, 2023: 32 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0926 | Have policies on smoking. Environmental Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| K | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| F | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0849 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0838 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| L | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| K | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0761 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| K | F-0726 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0690 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| G | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0657 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0656 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| E | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0585 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0584 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0578 | 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 | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/12/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
No fire safety citations published for this facility in the CMS Fire Safety Deficiencies file.
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| May 10, 2025 | Fine | $23,593 | — |
| December 16, 2023 | Fine | $83,814 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.19 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.36 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.98 | Not published | Not published |
| Nurse aide hours per resident per day | 1.85 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.7 | Not published | Not published |
| RN hours per resident per day, weekends | 0.23 | Not published | Not published |
| Total nursing staff turnover (%) | 52.1 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 37.5 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Fannin County Hospital Authority
- Ownership type
- Government - Hospital district
- Chain
- Eduro Healthcare (34 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 151
- Average residents per day
- 118.8
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- December 22, 1994
- County/parish
- Mc Lennan
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
7 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| FANNIN COUNTY HOSPITAL AUTHORITY | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| SANDERSON, CLARK | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| SHEDDY, THERESA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SANDERSON, CLARK | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WACO NURSING AND REHAB CENTER LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BEWSEY, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SHEDDY, THERESA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Lakeshore Village Nursing and Rehabilitation. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.