Lake Village Nursing And Rehabilitation Center
Lewisville, Denton County, Texas · CCN 675560 · For-profit (Corporation) · part of The Ensign Group (342 facilities, chain average 3.2 stars)
CMS rates Lake Village Nursing And Rehabilitation Center 1 of 5 overall as of August 2026. 112 certified beds, 77 residents a day on average. 33 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $24,585 and 1 payment denial.
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 | ★★☆☆☆ 2 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 4 / 4 of 5 |
Staffing
| Total nurse staffing | 3.07023 hours per resident per day |
|---|---|
| Registered nurses | 0.44475 hours per resident per day |
| Weekend total | 2.50937 hours per resident per day |
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 |
|---|---|---|---|
| 2026-05-05 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · tag F0851 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-05-08 |
| 2026-05-05 | 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 2026-05-08 |
| 2026-05-05 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-08 |
| 2026-05-05 | 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 2026-05-08 |
| 2026-05-05 | 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 2026-05-08 |
| 2026-05-05 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2026-05-05 | 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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2026-05-05 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2025-11-28 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 | Past Non-Compliance |
| 2025-11-28 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 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance |
| 2025-09-16 complaint survey |
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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-15 |
| 2025-09-16 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-15 |
| 2025-03-06 complaint survey |
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 2025-04-04 |
| 2025-03-06 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 2025-04-04 |
| 2025-03-06 complaint survey |
Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-04 |
| 2025-03-06 complaint survey |
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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-04 |
| 2025-03-06 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-04 |
| 2025-03-06 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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-04 |
| 2025-03-06 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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-04 |
| 2024-12-04 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 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-31 |
| 2024-12-04 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 2024-12-31 |
| 2024-01-26 complaint survey |
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 2024-02-28 |
| 2024-01-26 complaint survey |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · tag F0727 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-02-28 |
| 2024-01-26 complaint survey |
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 2024-02-28 |
| 2024-01-26 | 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 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-28 |
| 2024-01-26 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 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-28 |
| 2024-01-26 | 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 2024-02-28 |
| 2024-01-26 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 2024-02-28 |
| 2024-01-26 complaint survey |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-28 |
| 2024-01-26 complaint survey |
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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-28 |
| 2024-01-26 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 2024-02-28 |
| 2024-01-26 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-28 |
| 2024-01-26 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-28 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-01-26 | Payment denial for 8 days from 2024-02-28 | — |
| 2024-01-26 | Fine | $24,585 |
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 |
|---|---|---|---|
| Eastland Memorial Hospital District Organization | 5% or greater direct ownership interest | 100% | 2017-04-01 |
| Caretrust Gp LLC Organization | adp of the snf | — | 2007-03-01 |
| Caretrust Reit Inc. Organization | adp of the snf | — | 2007-03-01 |
| Ctr Partnership Lp Organization | adp of the snf | — | 2007-03-01 |
| Ensign Services Inc. Organization | adp of the snf | — | 2007-03-01 |
| Grand Villa Phx, Inc. Organization | adp of the snf | — | 2025-08-13 |
| Verde Villa Holdings LLC Organization | adp of the snf | — | 2007-03-01 |
| Grand Villa Phx, Inc. Organization | operational/managerial control | — | 2017-04-01 |
| Hernandez, Miguel Individual | adp of the snf | — | 2023-09-01 |
| Mall, Allen Individual | adp of the snf | — | 2007-03-01 |
| Burnam, Soon Individual | corporate officer | — | 2007-03-01 |
| Keetch, Chad Individual | corporate officer | — | 2011-03-01 |
| Taylor, Stephen Individual | corporate officer | — | 2025-07-01 |
| Hernandez, Miguel Individual | managing control - governing body | — | 2023-09-01 |
| Mall, Allen Individual | managing control - governing body | — | 2007-03-01 |
| Hernandez, Miguel Individual | operational/managerial control | — | 2023-09-01 |
| Mall, Allen Individual | operational/managerial control | — | 2007-03-01 |
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 Lake Village Nursing And Rehabilitation Center.
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 Denton County.