Lakeshore Village Nursing and Rehabilitation

Nursing Home · Waco, TX

CMS overall rating 1/5 Government - Hospital district

CMS certification number675438

Contact & location

2320 Lake Shore DR
Waco, TX 76708
Mc Lennan County
Phone
(254) 752-1075
ZIP code
76708 – all care providers

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Facility details

Certified beds
151
Residents per day
118.8 (79% occupied)
Ownership
Government - Hospital district
Legal name
Fannin County Hospital Authority
Chain
Eduro Healthcare (34 facilities, avg 2.4★)
Medicare certified since
December 22, 1994
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 1/5
State avg 2.6
Health inspections★★★★★ 1/5
State avg 2.8
Staffing★★★★★ 2/5
State avg 1.9
Quality measures★★★★★ 4/5
State avg 3.7
Long-stay quality★★★★★ 5/5
Short-stay quality★★★★★ 4/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.19 (state 3.39 · U.S. 3.86)
Registered nurses (RN)
0.36 (state 0.43 · U.S. 0.69)
Licensed practical nurses
0.98 (state 0.95 · U.S. 0.86)
Nurse aides
1.85 (state 2.00 · U.S. 2.32)
Weekend total
2.70 (state 2.98 · U.S. 3.42)
Nursing staff turnover
52.1 (state 55.3 · U.S. 45.8)%
RN turnover
37.5 (state 54.6 · U.S. 42.9)%
Administrators who left
0 in the last year

Inspections

Last standard inspection
April 22, 2026
Health deficiencies (last cycle)
6.0 (state 9.3 · U.S. 9.3)
From complaints
2
Citations on record (3 years)
52 health · 0 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-04-22 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F0644 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 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.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-05-04
2026-04-22 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-05-04
2026-04-22 Post nurse staffing information every day.
F0732 · Nursing and Physician Services Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-04
2026-03-03 Provide immediate access to any resident.
F0562 · Resident Rights Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-03-04
2025-12-11 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-12
2025-05-10 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2025-05-11
2025-05-10 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 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.
F0803 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-03-14
2025-02-20 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-03-14
2025-02-20 Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F0557 · Resident Rights Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-14
2025-02-20 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 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.
F0561 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 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.
F0806 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-14
2025-02-20 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-14
2024-09-10 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-09-11
2024-08-21 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-05
2024-08-21 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-05
2024-06-29 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-06-30
2024-05-16 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-06-10
2023-12-16 Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F0835 · Administration Deficiencies · complaint inspection		 L
Immediate jeopardy to resident health or safety		 Corrected 2024-01-12
2023-12-16 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.
F0726 · Nursing and Physician Services Deficiencies · complaint inspection		 K
Immediate jeopardy to resident health or safety		 Corrected 2024-01-12
2023-12-16 Provide timely, quality laboratory services/tests to meet the needs of residents.
F0770 · Administration Deficiencies		 K
Immediate jeopardy to resident health or safety		 Corrected 2024-01-12
2023-12-16 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 K
Immediate jeopardy to resident health or safety		 Corrected 2024-01-12
2023-12-16 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2024-01-12
2023-12-16 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F0868 · Administration Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 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
F0655 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 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.
F0656 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide activities to meet all resident's needs.
F0679 · Quality of Life and Care Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F0804 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Have policies on smoking.
F0926 · Environmental Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 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.
F0578 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 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.
F0584 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 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.
F0585 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F0640 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 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.
F0657 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide care or services that was trauma informed and/or culturally competent.
F0699 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide or obtain dental services for each resident.
F0791 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12
2023-12-16 Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F0810 · Nutrition and Dietary Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-01-12

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

2 penalties in the last three years, including $107,407 in fines.

DateTypeAmount
2025-05-10Fine$23,593
2023-12-16Fine$83,814

Ownership & management

NameRoleSince
Fannin County Hospital Authority (organization)5%+ Direct Ownership Interest
Sanderson, Clark (individual)5%+ Direct Ownership Interest
Sheddy, Theresa (individual)Corporate Director · NOT APPLICABLE
Sanderson, Clark (individual)Corporate Officer · NOT APPLICABLE
Bewsey, Michael (individual)Operational/managerial Control · NOT APPLICABLE
Sheddy, Theresa (individual)Operational/managerial Control · NOT APPLICABLE
Waco Nursing and Rehab Center LLC (organization)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Lakeshore Village Nursing and Rehabilitation?

Lakeshore Village Nursing and Rehabilitation has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.

How many beds does Lakeshore Village Nursing and Rehabilitation have?

It has 151 certified beds and cares for about 119 residents per day.

Has Lakeshore Village Nursing and Rehabilitation been fined?

Yes. CMS lists 2 penalties totaling $107,407 in the last three years.

Who owns Lakeshore Village Nursing and Rehabilitation?

It is part of Eduro Healthcare and is classified as government - hospital district. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Lakeshore Village Nursing and Rehabilitation?

(254) 752-1075. The facility is located at 2320 Lake Shore DR, Waco, TX 76708.

Other nursing homes in Waco

Compare all nursing homes in Waco, TX →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.