Lakeshore Village Nursing and Rehabilitation
2320 Lake Shore Dr, Waco, TX 76708 · All homes in Waco
Lakeshore Village Nursing and Rehabilitation, a 151-bed government - hospital district nursing facility in Waco, TX, holds a 1-star CMS overall rating - below the 3.0-star national average, ranking #919 of 1,165 rated homes in TX on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 5 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 2547521075
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- 1 / 5
- Much below average · CMS overall · nat'l 3.0
- #919 of 1,165
- In-state rank among rated TX homes
- 3.19
- Well below average · nurse hrs/day · nat'l 3.86
- 50
- Inspection findings · 5 serious
If a nursing-home resident is in immediate danger, call 911.
For elder abuse or neglect concerns, contact your state's Adult Protective Services (search "APS" + your state) or call the Eldercare Locator at 1-800-677-1116. For facility advocacy, reach your Long-Term Care Ombudsman. CMS ratings and inspection data below are a research screen, not an emergency channel.
The verdict
Lakeshore Village Nursing and Rehabilitation, a 151-bed government - hospital district nursing facility in Waco, TX, holds a 1-star CMS overall rating - below the 3.0-star national average, ranking #919 of 1,165 rated homes in TX on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 5 inspection findings reached the actual-harm or immediate-jeopardy level.
- 1 / 5
- CMS overall · national 3.0
- #919 of 1,165
- In-state rank among rated TX homes
- 3.19
- Nurse hrs/resident-day · national 3.86
- 50
- Inspection findings · 5 serious
CMS force-curves overall stars within each state; read health, staffing, and quality sub-ratings alongside the headline.
In-state ownership mix · peer inventory
How 1,177 TX nursing homes split by ownership sector
This facility is recorded as Government - Hospital district. Sector buckets collapse CMS ownership_type into For-profit, Nonprofit, and Government, orthogonal to the RN/LPN/CNA hour bar below.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 675438
- Ownership
- Government - Hospital district
- Provider Type
- Medicare and Medicaid
- Beds
- 151
- Residents
- 119
- In Hospital
- No
- County
- Mc Lennan
- Last Inspection
- Apr 22, 2026
Staffing Data
How the 3.19 total nursing hours per resident-day are staffed:
- RN Hours
- 0.36 (nat'l avg: 0.69)
- LPN Hours
- 0.98
- CNA Hours
- 1.85
- Total Nursing Hours
- 3.19 (nat'l avg: 3.86)
- PT Hours
- 0.12
- Nursing Turnover
- 52.1%
- RN Turnover
- 37.5%
What the CMS Record Reveals About Lakeshore Village Nursing and Rehabilitation
According to CMS Nursing Home Compare, Lakeshore Village Nursing and Rehabilitation ranks #919 of 1,165 rated nursing homes in TX on overall stars (tie-broken by health+staffing+quality, then fewer fines). Lakeshore Village Nursing and Rehabilitation operates 151 certified beds in Waco, TX with approximately 119 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars (health inspection 1★ · staffing 2★ · quality 4★).
The inspection file contains 50 deficiency records from recent surveys, of which 5 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. CMS enforcement records show 2 penalties totaling $107K levied against this facility. Staffing is reported at 3.19 total nursing hours per resident day (national average 3.86), with RN coverage at 0.36 per resident day.
Classified as "Government - Hospital district" ownership and operating as a "Medicare and Medicaid" provider, Lakeshore Village Nursing and Rehabilitation falls into a category where comparative context matters. Reported nursing staff turnover at this facility is 52.1% (CMS payroll-based measure).
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify the same record on Medicare.gov Care Compare and with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: May 4, 2026
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 4, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: May 4, 2026
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 4, 2026
Provide immediate access to any resident.
Category: Resident Rights Deficiencies
Corrected: Mar 4, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 12, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: May 11, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: May 11, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 14, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 14, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Mar 14, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Mar 14, 2025
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category: Resident Rights Deficiencies
Corrected: Mar 14, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 14, 2025
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 14, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 11, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 5, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 5, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 30, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 10, 2024
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.
Category: Administration Deficiencies
Corrected: Jan 12, 2024
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.
Category: Administration Deficiencies
Corrected: Jan 12, 2024
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 12, 2024
Provide or obtain dental services for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jan 12, 2024
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 12, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 12, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jan 12, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jan 12, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jan 12, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Jan 12, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jan 12, 2024
Have policies on smoking.
Category: Environmental Deficiencies
Corrected: Jan 12, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 12, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Jan 12, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jan 12, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 12, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 12, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Jan 12, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 12, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 12, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 12, 2024
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Jan 12, 2024
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 14.2% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.4% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.2% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.8% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.2% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 5.2% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.7% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 6.2% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 19.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 14.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 96.9% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 89.0% | No |
Penalty History 2 penalties totaling $107K
| Date | Type | Amount |
|---|---|---|
| May 10, 2025 | Fine | $24K |
| Dec 16, 2023 | Fine | $84K |
Nationwide facilities with similar scale or staffing
Two data-derived peer sets for Lakeshore Village Nursing and Rehabilitation, both outside TX so the neighborhoods are not the same-state geography list below.
Similar bed count
Nearest CMS certified bed counts outside TX (151 beds here).
Similar staffing hours
Nearest CMS adjusted total nurse hours per resident day outside TX (3.24 here).
Nearby Nursing Homes in TX
1,176 other nursing homes are on record in TX; 6 are shown here.
600 Maple Ave.
Burleson, TX
Accel at College Station
College Station, TX
Accel at Willow Bend
Plano, TX
Advanced Health & Rehab Center of Garland
Garland, TX
Advanced Rehabilitation & Healthcare of Burleson
Burleson, TX
Advanced Rehabilitation & Healthcare of Live Oak
Live Oak, TX
Understanding Nursing Home Data
What the CMS records show for Lakeshore Village Nursing and Rehabilitation
The health, staffing, and quality sub-ratings above often diverge from the CMS overall headline. Use those components and the inspection findings to read the full file, not the overall star alone.
- The TX registry aggregates state averages and the highest-rated homes in this cohort. View TX registry
- Peer homes near 151 beds show how CMS stars vary at a similar scale in TX. Compare a similar-size peer
- CMS publishes separate fields for inspections, nurse staffing hours, and quality measures; the guide explains how each star is computed. How CMS ratings work
CMS refreshes Nursing Home Compare quarterly (current extract: August 2026). PlainNursing describes published records; it does not establish suitability, availability, admissions, or individual outcomes.
Frequently Asked Questions
What is the overall CMS rating for Lakeshore Village Nursing and Rehabilitation?
Where does Lakeshore Village Nursing and Rehabilitation rank among nursing homes in TX?
What are the staffing levels at Lakeshore Village Nursing and Rehabilitation?
How many beds does Lakeshore Village Nursing and Rehabilitation have?
Does Lakeshore Village Nursing and Rehabilitation have any deficiencies on record?
Has Lakeshore Village Nursing and Rehabilitation received any fines or penalties?
Who owns Lakeshore Village Nursing and Rehabilitation?
When was Lakeshore Village Nursing and Rehabilitation last inspected?
What quality measures are tracked for Lakeshore Village Nursing and Rehabilitation?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Verify the same CCN on Medicare.gov Care Compare and with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
