Report
TheVardellReport
Lakeshore Village Nursing and Rehabilitation
Skilled nursing facility and nursing facility
2320 Lake Shore Dr
Waco, TX 76708
Report
← Lakeshore Village Nursing and Rehabilitation, free profile
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The Vardell Report.Lakeshore Village Nursing and Rehabilitation
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Waco, TX
- Record Period
- 2023–2026
- Source Documents
- 14
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 12 inspections from December 2023 to August 2026, state surveyors documented 53 findings at Lakeshore Village Nursing and Rehabilitation; 53 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 12
- 2023–2026, complaint, standard and infection control
- Findings
- 53
- Deficiencies cited by state inspectors
- Corrected
- 53
- Of 53 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 32 | 5 |
| 2024 | 5 | 5 | 0 |
| 2025 | 3 | 10 | 2 |
| 2026 | 3 | 6 | 0 |
What the Record Shows
- 53 of 53 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $107,407, their payment not published.
- 10 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, April 22, 2026, recorded 4 findings (most serious: Level E).
What to Ask About
- Kitchen and Food Safety, Cited in Four Inspections
- Needs and Preferences, Cited in Three Inspections
- Help With Daily Living, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Pharmacy Services, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
Report at a Glance
- Facility
- Lakeshore Village Nursing and Rehabilitation
- Address
- 2320 Lake Shore Dr, Waco, TX 76708
- CMS Certification Number
- 675438
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 151
- Ownership
- Government - Hospital district
- Record Window
- December 16, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Aug 24, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Standard health inspection
4 findings
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level ENo actual harm, potential for moreCorrected May 4, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 4, 2026
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 4, 2026
- F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected May 4, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
1 finding
- F562Provide immediate access to any resident.Level FNo actual harm, potential for moreCorrected Mar 4, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level JImmediate jeopardyCorrected May 11, 2025
- F692Provide enough food/fluids to maintain a resident's health.Level JImmediate jeopardyCorrected May 11, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
7 findings
The same visit included a complaint investigation.
- F803Ensure 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.Level FNo actual harm, potential for moreCorrected Mar 14, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 14, 2025
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level ENo actual harm, potential for moreCorrected Mar 14, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Mar 14, 2025
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Mar 14, 2025
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level ENo actual harm, potential for moreCorrected Mar 14, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 14, 2025
Enforcement Action
Civil money penalty, $23,593 imposed May 10, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 20, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Sep 11, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Sep 5, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 5, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jun 30, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 10, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Infection control inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
32 findings
The same visit included a complaint investigation.
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level LImmediate jeopardyCorrected Jan 12, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level KImmediate jeopardyCorrected Jan 12, 2024
- F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level KImmediate jeopardyCorrected Jan 12, 2024
- F880Provide and implement an infection prevention and control program.Level KImmediate jeopardyCorrected Jan 12, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jan 12, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 12, 2024
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Jan 12, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Jan 12, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F926Have policies on smoking.Level ENo actual harm, potential for moreCorrected Jan 12, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F578Honor 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.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F584Honor 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.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F838Conduct 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.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Jan 12, 2024
Enforcement Action
Civil money penalty, $83,814 imposed December 16, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 16, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Kitchen and Food Safety, Cited in Four Inspections
Inspectors cited F812 in December 2023, June 2024, February 2025 and April 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242424252525262626F812 across all 12 inspections, oldest to newest - 2
Needs and Preferences, Cited in Three Inspections
Inspectors cited F558 in December 2023, February 2025 and August 2026. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242424252525262626F558 across all 12 inspections, oldest to newest - 3
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in December 2023 and February 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242424252525262626F677 across all 12 inspections, oldest to newest - 4
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in December 2023 and December 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242424252525262626F689 across all 12 inspections, oldest to newest - 5
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in December 2023 and May 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242424252525262626F755 across all 12 inspections, oldest to newest - 6
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in December 2023 and September 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242424252525262626F761 across all 12 inspections, oldest to newest - 7
Infection Control, Cited in Two Inspections
Inspectors cited F880 in December 2023 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232424242424252525262626F880 across all 12 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in four inspections, most seriously at level F.
- 02
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in three inspections, most seriously at level E.
- 03
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level D.
- 04
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level E.
- 05
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level E.
- 06
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level E.
- 07
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level K.
- 08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 09
What led to the 2025 fine, and has it been paid?
A $23,593 civil money penalty was imposed May 10, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Dec 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Mar 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection May 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jun 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Aug 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Sep 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Feb 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection May 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Dec 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Mar 3, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Apr 22, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Aug 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 675438
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowDecember 16, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before December 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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