Lakeshore Village Nursing and Rehabilitation
2320 Lake Shore Dr, Waco, TX 76708
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Follow this homeLakeshore Village Nursing and Rehabilitation is a nursing home in Waco, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionApril 22, 2026 (6 months ago)
- Health citations since December 16, 202353 (Texas average 28)
- Fines in the past three years2, $107,407 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
Health inspection on August 21, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on August 24, 2026.
CMS has cited this home for F0558 3 times since 2023.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on April 22, 2026
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0644. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on May 4, 2026.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 4, 2026.
CMS has cited this home for F0812 4 times since 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 4, 2026.
CMS has cited this home for F0880 2 times since 2023.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on May 4, 2026.
Health inspection on March 3, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0562. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide immediate access to any resident.
CMS lists it as corrected on March 4, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Fine
CMS changed the fine from May 10, 2025 from $23,212 to $23,593.
CMS update of January 14, 2026
Fine
CMS changed the fine from May 10, 2025 from $35,710 to $23,212.
Health inspection on December 11, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 12, 2025.
CMS has cited this home for F0689 2 times since 2023.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health citation
CMS changed citation F0580 from severity K to J. It is from the health inspection on May 10, 2025. Severity J: immediate jeopardy, isolated.
Health citation
CMS changed citation F0692 from severity K to J. It is from the health inspection on May 10, 2025. Severity J: immediate jeopardy, isolated.
CMS update of May 28, 2025
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Health inspection on May 10, 2025
2 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $23,593 on May 10, 2025.
Show the 2 citations
Citation F0580. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on May 11, 2025.
Citation F0692. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 11, 2025.
Health inspection on February 20, 2025
7 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 7 citations
Citation F0803. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on March 14, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 14, 2025.
Citation F0557. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on March 14, 2025.
Citation F0558. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on March 14, 2025.
Citation F0561. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on March 14, 2025.
Citation F0806. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on March 14, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on March 14, 2025.
CMS has cited this home for F0677 2 times since 2023.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Health inspection on September 10, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 11, 2024.
CMS has cited this home for F0761 2 times since 2023.
Health inspection on August 21, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on September 5, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 5, 2024.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on June 29, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 30, 2024.
CMS update of May 29, 2024
Fine
CMS changed the fine from December 16, 2023 from $128,945 to $83,814.
Health inspection on May 16, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 10, 2024.
CMS has cited this home for F0755 2 times since 2023.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of February 29, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Health inspection on December 16, 2023
32 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
152 of 1,177 Texas homes (13%) got a citation at the immediate jeopardy level in 2023.
CMS fine of $83,814 on December 16, 2023.
Show the 32 citations
Citation F0835. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on January 12, 2024.
Citation F0726. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
Citation F0770. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on January 12, 2024.
Citation F0880. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 12, 2024.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on January 12, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 12, 2024.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on January 12, 2024.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on January 12, 2024.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 12, 2024.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on January 12, 2024.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on January 12, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 12, 2024.
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on January 12, 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on January 12, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on January 12, 2024.
Citation F0926. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have policies on smoking.
CMS lists it as corrected on January 12, 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 12, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on January 12, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
Citation F0640. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on January 12, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on January 12, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on January 12, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on January 12, 2024.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on January 12, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on January 12, 2024.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on January 12, 2024.
Citation F0810. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
CMS lists it as corrected on January 12, 2024.
Citation F0838. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 12, 2024.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (254) 752-1075
- Last standard health inspection
- April 22, 2026 (6 months ago)
- Certified beds
- 151
- Residents per day, on average
- 120.3
- Ownership type
- Government - Hospital district
- Legal business name
- Fannin County Hospital Authority
- Chain
- Eduro Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Texas average (53 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- FANNIN COUNTY HOSPITAL AUTHORITY5% or greater direct ownership interest · no percentage provided · since 04/01/2022
- SANDERSON, CLARK5% or greater direct ownership interest · no percentage provided · since 04/01/2022
- LSSH WACO II, LLCOperational/managerial control · not applicable · since 08/01/2026
- SCHWEDOCK, NICHOLASOperational/managerial control · not applicable · since 08/01/2026
- WARD, TRAVISOperational/managerial control · not applicable · since 08/01/2026
Questions
When was Lakeshore Village Nursing and Rehabilitation last inspected?
CMS lists April 22, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Lakeshore Village Nursing and Rehabilitation have?
CMS lists 53 health citations since December 16, 2023. CMS also calls these deficiencies.
Has Lakeshore Village Nursing and Rehabilitation been fined?
CMS lists 2 fines in the past three years, $107,407 in total.
What is the CMS star rating of Lakeshore Village Nursing and Rehabilitation?
Its CMS overall star rating is 1 of 5.
Is Lakeshore Village Nursing and Rehabilitation a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.