Federal Nursing-Home Survey Record
LAKESHORE VILLAGE NURSING AND REHABILITATION
Does LAKESHORE VILLAGE NURSING AND REHABILITATION have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), LAKESHORE VILLAGE NURSING AND REHABILITATION (CCN 675438), in WACO, TX, has federal inspection findings on its record. In its current inspection cycle, CMS cited the facility for 11 deficiencies; the most serious carries scope/severity J on CMS's A–L scale, a level CMS classifies as Immediate Jeopardy. The most recent federal survey on file is dated 2025-02-20. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $135,984 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.
The Federal Record
At its most recent federal inspection, CMS cited this facility for an Immediate Jeopardy deficiency.
Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.
Scope & Severity — current cycle
Civil money penalties on file
$135,984
CMS has $135,984 in civil money penalties on file against this facility.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 2.7
Deficiency timeline — full federal history
Provide immediate access to any resident.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Provide and implement an infection prevention and control program.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide activities to meet all resident's needs.
Have policies on smoking.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Reasonably accommodate the needs and preferences of each resident.
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.
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.
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.
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide care or services that was trauma informed and/or culturally competent.
Ensure medication error rates are not 5 percent or greater.
Provide or obtain dental services for each resident.
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
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.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Document what happened
Were you or a loved one harmed at LAKESHORE VILLAGE NURSING AND REHABILITATION?
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Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.