Lakeshore Village Nursing and Rehabilitation

2320 Lake Shore Dr, Waco, TX 76708

Phone: 2547521075

CMS ratings and facility information

Lakeshore Village Nursing and Rehabilitation is a Medicare-certified nursing facility in Waco, Mc Lennan County, Texas. CMS data for this profile was updated August 2026. Ratings and facility details can change; confirm current information with CMS and the facility.

CMS overall rating1 of 5 stars
Health inspection rating1 of 5
Staffing rating2 of 5
Quality measures rating4 of 5
Certified beds151
OwnershipGovernment - Hospital district
CMS certification number675438

Staffing

Total nurse hours per resident day3.19
RN hours per resident day0.36
Nurse aide hours per resident day1.85
Total nursing staff turnover percent52.1
RN turnover percent37.5

Resident outcome measures

MeasureValueUnitPeriod
Hospitalizations1.49events_per_1000_resident_days20250101-20251231
Emergency-department visits2.08events_per_1000_resident_days20250101-20251231
Falls with major injury1.7percent2025Q2-2026Q1
Pressure ulcers5.17percent2025Q2-2026Q1
Urinary tract infections2.2percent2025Q2-2026Q1
Antipsychotic medication use5.17percent2025Q2-2026Q1

Health inspection citations

Survey dateTagCitationSeverity
2026-04-220644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.E
2026-04-220812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E
2026-04-220880Provide and implement an infection prevention and control program.E
2026-04-220732Post nurse staffing information every day.D
2025-02-200803Ensure 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
2025-02-200812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2025-02-200557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.E
2025-02-200558Reasonably accommodate the needs and preferences of each resident.E
2025-02-200561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.E
2025-02-200806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.E
2025-02-200677Provide care and assistance to perform activities of daily living for any resident who is unable.D
2023-12-160835Administer the facility in a manner that enables it to use its resources effectively and efficiently.L
2023-12-160726Ensure 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
2023-12-160770Provide timely, quality laboratory services/tests to meet the needs of residents.K
2023-12-160880Provide and implement an infection prevention and control program.K
2023-12-160686Provide appropriate pressure ulcer care and prevent new ulcers from developing.G
2023-12-160812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2023-12-160868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyF
2023-12-160655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedE
2023-12-160656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E
2023-12-160658Ensure services provided by the nursing facility meet professional standards of quality.E
2023-12-160679Provide activities to meet all resident's needs.E
2023-12-160689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E
2023-12-160695Provide safe and appropriate respiratory care for a resident when needed.E
2023-12-160755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E
2023-12-160761Ensure 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
2023-12-160804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.E
2023-12-160926Have policies on smoking.E
2023-12-160550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D
2023-12-160558Reasonably accommodate the needs and preferences of each resident.D
2023-12-160578Honor 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
2023-12-160584Honor 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
2023-12-160585Honor 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
2023-12-160640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.D
2023-12-160657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D
2023-12-160677Provide care and assistance to perform activities of daily living for any resident who is unable.D
2023-12-160690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D
2023-12-160699Provide care or services that was trauma informed and/or culturally competent.D
2023-12-160759Ensure medication error rates are not 5 percent or greater.D
2023-12-160791Provide or obtain dental services for each resident.D
2023-12-160810Provide special eating equipment and utensils for residents who need them and appropriate assistance.D
2023-12-160838Conduct 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
2023-12-160849Arrange 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

Penalties

DateTypeAmount
2025-05-10Fine,593
2023-12-16Fine,814

Ownership records

NameTypeRole
FANNIN COUNTY HOSPITAL AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST
SANDERSON, CLARKIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST
SHEDDY, THERESAIndividualCORPORATE DIRECTOR
SANDERSON, CLARKIndividualCORPORATE OFFICER
WACO NURSING AND REHAB CENTER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL
BEWSEY, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL
SHEDDY, THERESAIndividualOPERATIONAL/MANAGERIAL CONTROL

Compare nursing homes in Mc Lennan County, Texas.

Source: Centers for Medicare & Medicaid Services Care Compare data. Data snapshot: August 2026. Read Our Data & Methodology. This directory does not provide medical or legal advice.