F59

LAKESHORE VILLAGE NURSING AND REHABILITATION

Grade F 59/100 composite score

Government - Hospital district

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

151

Ownership

Government - Hospital district

Total Fines

$135,603

Last Survey

N/A

2320 LAKE SHORE DR, WACO, TX 76708
2547521075

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.36h
LPN
1.10h
CNA
2.27h
Total
3.73h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

FANNIN COUNTY HOSPITAL AUTHORITY

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Apr 2022

SANDERSON, CLARK

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Apr 2022

WACO NURSING AND REHAB CENTER LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Sep 2022

BEWSEY, MICHAEL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2022

SHEDDY, THERESA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2016

SHEDDY, THERESA

IndividualCORPORATE DIRECTORSince Sep 2016

SANDERSON, CLARK

IndividualCORPORATE OFFICERSince Oct 2012

Penalties & Fines (3)

$135,603total fines
DateTypeDescriptionAmount
May 10, 2025Fine$23,212
Dec 16, 2023Fine$83,814
Jun 26, 2023Fine$28,577

Health Inspection Deficiencies (49)

May 10, 2025Health2 deficiencies2 severe
0580JImmediate jeopardy, Isolated

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

Corrected May 11, 2025
0692JImmediate jeopardy, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected May 11, 2025
February 20, 2025Health7 deficiencies
0558EMinimal harm, Pattern

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Mar 14, 2025
0561EMinimal harm, Pattern

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Mar 14, 2025
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Mar 14, 2025
0803FMinimal harm, Widespread

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

Corrected Mar 14, 2025
0806EMinimal harm, Pattern

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

Corrected Mar 14, 2025
0557EMinimal harm, Pattern

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Resident Rights Deficiencies

Corrected Mar 14, 2025
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 14, 2025
September 10, 2024Health1 deficiency
0761EMinimal harm, Pattern

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

Corrected Sep 11, 2024
August 21, 2024Health2 deficiencies
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Sep 5, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Sep 5, 2024
June 29, 2024Health1 deficiency
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jun 30, 2024
May 16, 2024Health1 deficiency
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jun 10, 2024
December 16, 2023Health32 deficiencies5 severe
0640DMinimal harm, Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 12, 2024
0655EMinimal harm, Pattern

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

Corrected Jan 12, 2024
0656EMinimal harm, Pattern

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

Corrected Jan 12, 2024
0657DMinimal harm, Isolated

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

Corrected Jan 12, 2024
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 12, 2024
0770KImmediate jeopardy, Pattern

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Corrected Jan 12, 2024
0791DMinimal harm, Isolated

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Corrected Jan 12, 2024
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Jan 12, 2024
0810DMinimal harm, Isolated

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Nutrition and Dietary Deficiencies

Corrected Jan 12, 2024
0868FMinimal harm, Widespread

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Administration Deficiencies

Corrected Jan 12, 2024
0880KImmediate jeopardy, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jan 12, 2024
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jan 12, 2024
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Jan 12, 2024
0578DMinimal harm, Isolated

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

Corrected Jan 12, 2024
0584DMinimal harm, Isolated

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

Corrected Jan 12, 2024
0585DMinimal harm, Isolated

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

Corrected Jan 12, 2024
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jan 12, 2024
0679EMinimal harm, Pattern

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Jan 12, 2024
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jan 12, 2024
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jan 12, 2024
0690DMinimal harm, Isolated

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

Corrected Jan 12, 2024
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Jan 12, 2024
0699DMinimal harm, Isolated

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies

Corrected Jan 12, 2024
0726KImmediate jeopardy, Pattern

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

Corrected Jan 12, 2024
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jan 12, 2024
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Jan 12, 2024
0761EMinimal harm, Pattern

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

Corrected Jan 12, 2024
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jan 12, 2024
0835LImmediate jeopardy, Widespread

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Corrected Jan 12, 2024
0838DMinimal harm, Isolated

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

Corrected Jan 12, 2024
0849DMinimal harm, Isolated

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

Corrected Jan 12, 2024
0926EMinimal harm, Pattern

Have policies on smoking.

Environmental Deficiencies

Corrected Jan 12, 2024
June 26, 2023Health1 deficiency1 severe
0689KImmediate jeopardy, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jun 27, 2023
February 2, 2023Health1 deficiency
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Feb 9, 2023
January 10, 2023Health1 deficiency
0761EMinimal harm, Pattern

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

Corrected Jan 17, 2023

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Frequently Asked Questions

What is the CareGrader rating for LAKESHORE VILLAGE NURSING AND REHABILITATION?

LAKESHORE VILLAGE NURSING AND REHABILITATION in WACO, Texas has a CareGrader grade of F (Poor), with a composite score of 59 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for LAKESHORE VILLAGE NURSING AND REHABILITATION?

LAKESHORE VILLAGE NURSING AND REHABILITATION has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does LAKESHORE VILLAGE NURSING AND REHABILITATION have?

LAKESHORE VILLAGE NURSING AND REHABILITATION has 49 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has LAKESHORE VILLAGE NURSING AND REHABILITATION been fined?

Yes. LAKESHORE VILLAGE NURSING AND REHABILITATION has $135,603 in total fines from CMS enforcement actions across 3 penalties.

How many beds does LAKESHORE VILLAGE NURSING AND REHABILITATION have?

LAKESHORE VILLAGE NURSING AND REHABILITATION has 151 certified beds with approximately 120 current residents (79% occupancy). The facility is located at 2320 LAKE SHORE DR, WACO, Texas 76708. It is a government - hospital district facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.