Lakeshore Village Nursing and RehabilitationCMS ratings, inspections and fines
- Address
- 2320 Lake Shore Dr, Waco, TX 76708
- CCN
- 675438
- Ownership type
- Government, hospital district
- Certified beds
- 151
- Chain
- Eduro Healthcare
- Residents per day
- 119
- CMS flags
- None in the CMS record
Open the watch listCare Compare record (Medicare.gov)
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Lakeshore Village Nursing and Rehabilitation an overall rating of 1 of 5 stars. The last standard survey was on 22 Apr 2026. The latest survey cycle has 6 health citations. The median for nursing homes in Texas is 8. CMS lists 2 fines with a total of $107,407 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | McLennan County median | Texas median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 1 | 2.0 | 3.0 | 3.0 |
| Health inspection rating | 1 | 2.0 | 3.0 | 2.8 |
| Staffing rating | 2 | 2.0 | 2.0 | 2.9 |
| Quality measure rating | 4 | 3.0 | 4.0 | 3.6 |
A median is the middle value of the homes in the group: 18 homes in the county, 1,177 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Texas median |
|---|---|---|---|
| Cycle 1 (latest) | 22 Apr 2026 | 6 | 8 |
| Cycle 2 | 20 Feb 2025 | 12 | 8 |
| Cycle 3 | No date | 34 | 8 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | |||
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 6 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 22 Apr 2026 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | E | Standard survey | 4 May 2026 |
| 22 Apr 2026 | F0732 | Post nurse staffing information every day. | D | Standard survey | 4 May 2026 |
| 22 Apr 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 4 May 2026 |
| 22 Apr 2026 | F0880 | Provide and implement an infection prevention and control program. | E | Standard survey | 4 May 2026 |
| 3 Mar 2026 | F0562 | Provide immediate access to any resident. | F | Complaint investigation | 4 Mar 2026 |
| 11 Dec 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 12 Dec 2025 |
Survey cycle 2: 12 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 10 May 2025 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | J | Complaint investigation | 11 May 2025 |
| 10 May 2025 | F0692 | Provide enough food/fluids to maintain a resident's health. | J | Complaint investigation | 11 May 2025 |
| 20 Feb 2025 | F0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | E | Complaint investigation | 14 Mar 2025 |
| 20 Feb 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident. | E | Standard survey | 14 Mar 2025 |
| 20 Feb 2025 | F0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | E | Standard survey | 14 Mar 2025 |
| 20 Feb 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 14 Mar 2025 |
| 20 Feb 2025 | F0803 | 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. | F | Standard survey | 14 Mar 2025 |
| 20 Feb 2025 | F0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | E | Standard survey | 14 Mar 2025 |
| 20 Feb 2025 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint investigation | 14 Mar 2025 |
| 10 Sep 2024 | F0761 | 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. | E | Complaint investigation | 11 Sep 2024 |
| 21 Aug 2024 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint investigation | 5 Sep 2024 |
| 21 Aug 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 5 Sep 2024 |
Survey cycle 3: 34 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 29 Jun 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Complaint investigation | 30 Jun 2024 |
| 16 May 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint investigation | 10 Jun 2024 |
| 16 Dec 2023 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0558 | Reasonably accommodate the needs and preferences of each resident. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0578 | 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. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0584 | 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. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0585 | 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. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | D | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0679 | Provide activities to meet all resident's needs. | E | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0699 | Provide care or services that was trauma informed and/or culturally competent. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0726 | 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. | K | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0761 | 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. | E | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. | K | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0791 | Provide or obtain dental services for each resident. | D | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | L | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0838 | 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. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0849 | 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. | D | Complaint investigation | 12 Jan 2024 |
| 16 Dec 2023 | F0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0880 | Provide and implement an infection prevention and control program. | K | Standard survey | 12 Jan 2024 |
| 16 Dec 2023 | F0926 | Have policies on smoking. | E | Complaint investigation | 12 Jan 2024 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 10 May 2025 | Fine | $23,593 | |
| 16 Dec 2023 | Fine | $83,814 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Texas median | Texas average (CMS) |
|---|---|---|---|
| All nurse staff | 3.19 | 3.30 | 3.39 |
| Registered nurses (RN) | 0.36 | 0.40 | 0.43 |
| Licensed practical nurses (LPN) | 0.98 | 0.95 | |
| Nurse aides | 1.85 | 2.00 | |
| All nurse staff, weekends | 2.70 | 2.90 | 2.98 |
- Nurse staff turnover in a year
- 52.1%
- Nurse staff turnover, Texas median
- 52.1%
- RN turnover in a year
- 37.5%
- Administrators who left in a year
- 0
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Texas median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 14.2% | 14.9% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.4% | 0.0% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.2% | 0.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.7% | 3.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.5% | 0.7% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.8% | 12.4% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.2% | 3.4% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 5.2% | 8.3% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- Government, hospital district
- Legal business name
- Fannin County Hospital Authority
- Chain
- Eduro Healthcare (34 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Fannin County Hospital Authority | 5% or greater direct ownership interest | 1 Apr 2022 | |
| Waco Nursing and Rehab Center LLC | Operational/managerial control | 1 Sep 2022 |
The site shows organisations only. It does not show the names of persons.
Other homes in McLennan County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Crestview Healthcare Residence | Waco | 4 of 5 | 4 | $56,550 | 19 Jun 2025 | |
| Ivy Creek Wellness & Rehabilitation | Waco | 1 of 5 | 9 | $149,039 | 23 Jul 2025 | |
| The Atrium of Bellmead | Bellmead | 1 of 5 | 3 | $27,853 | 12 Feb 2026 | |
| Woodland Springs Nursing Center | Waco | 1 of 5 | 10 | $92,215 | 4 Dec 2025 | |
| Avir at Jeffrey Place | Waco | 3 of 5 | 3 | $22,382 | 9 Apr 2026 | |
| Ridgecrest Retirement and Healthcare Community | Waco | 1 of 5 | 13 | $14,267 | 15 Jun 2025 | |
| St. Catherine Center | Waco | 5 of 5 | 5 | $13,065 | 30 Apr 2026 | |
| Greenview Nursing and Rehabilitation | Waco | 1 of 5 | 17 | $73,108 | 19 Mar 2025 | |
| Woodway Rehabilitation and Healthcare Center | Waco | 2 of 5 | 4 | $14,952 | 5 Jun 2025 | |
| The Chateau Waco | Waco | 1 of 5 | 7 | $72,056 | 19 Mar 2026 | |
| Wesley Woods Health & Rehabilitation | Waco | 2 of 5 | 6 | $55,900 | 31 Dec 2025 | |
| Avir at Waco | Waco | 4 of 5 | 7 | $0 | 6 Feb 2026 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Texas Health and Human Services: complaint and incident intakeThe complaint page of the State Survey Agency for Texas, from the CMS list of agencies.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Lakeshore Village Nursing and Rehabilitation (CCN 675438). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/lakeshore-village-nursing-and-rehabilitation-waco-tx-675438/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Lakeshore Village Nursing and Rehabilitation last inspected?
- The latest inspection with a citation in the CMS record was on 22 Apr 2026. It was a standard survey. It gave 4 citations. The standard survey before the last one was on 20 Feb 2025.
- Who operates Lakeshore Village Nursing and Rehabilitation?
- The CMS record gives the ownership type as government, hospital district. CMS lists the home in the chain Eduro Healthcare. The CMS ownership file names Waco Nursing and Rehab Center LLC for operational or managerial control. This site does not show the names of persons.
- Is Lakeshore Village Nursing and Rehabilitation a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 6 homes in Texas as Special Focus Facilities and 30 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.