Lakeshore Village Nursing And Rehabilitation
Waco, Mc Lennan County, Texas · CCN 675438 · Government (Hospital district) · part of Eduro Healthcare (34 facilities, chain average 2.4 stars)
CMS rates Lakeshore Village Nursing And Rehabilitation 1 of 5 overall as of August 2026. 151 certified beds, 119 residents a day on average. 52 citations on record from the current inspection cycles, 6 at immediate jeopardy; 2 fines totalling $107,407.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 5 / 4 of 5 |
Staffing
| Total nurse staffing | 3.19384 hours per resident per day |
|---|---|
| Registered nurses | 0.35768 hours per resident per day |
| Weekend total | 2.69966 hours per resident per day |
| Nursing staff turnover | 52.1% (registered nurses 37.5%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-22 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · tag F0644 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-04 |
| 2026-04-22 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-04 |
| 2026-04-22 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-04 |
| 2026-04-22 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-04 |
| 2026-03-03 complaint survey |
Provide immediate access to any resident. Resident Rights Deficiencies · tag F0562 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-03-04 |
| 2025-12-11 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-12 |
| 2025-05-10 complaint survey |
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 · tag F0580 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-05-11 |
| 2025-05-10 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2025-05-11 |
| 2025-02-20 | 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 · tag F0803 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-03-14 |
| 2025-02-20 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-03-14 |
| 2025-02-20 complaint survey |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · tag F0557 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-14 |
| 2025-02-20 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-14 |
| 2025-02-20 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-14 |
| 2025-02-20 | 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 · tag F0806 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-14 |
| 2025-02-20 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-14 |
| 2024-09-10 complaint survey |
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 · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-09-11 |
| 2024-08-21 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-05 |
| 2024-08-21 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-09-05 |
| 2024-06-29 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-30 |
| 2024-05-16 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-10 |
| 2023-12-16 complaint survey |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · tag F0835 |
L Immediate jeopardy to resident health or safety; widespread | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0726 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · tag F0770 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · tag F0868 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | 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 · tag F0655 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | 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 · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Have policies on smoking. Environmental Deficiencies · tag F0926 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · tag F0640 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | 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 · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · tag F0810 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0838 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
| 2023-12-16 complaint survey |
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 · tag F0849 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-12 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-05-10 | Fine | $23,593 |
| 2023-12-16 | Fine | $83,814 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Fannin County Hospital Authority Organization | 5% or greater direct ownership interest | — | 2022-04-01 |
| Waco Nursing And Rehab Center LLC Organization | operational/managerial control | — | 2022-09-01 |
| Sanderson, Clark Individual | 5% or greater direct ownership interest | — | 2022-04-01 |
| Sheddy, Theresa Individual | corporate director | — | 2016-09-01 |
| Sanderson, Clark Individual | corporate officer | — | 2012-10-29 |
| Bewsey, Michael Individual | operational/managerial control | — | 2022-09-01 |
| Sheddy, Theresa Individual | operational/managerial control | — | 2016-09-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Lakeshore Village Nursing And Rehabilitation.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Mc Lennan County.