Map showing the location of LAKESHORE VILLAGE NURSING AND REHABILITATION in WACO, Texas
2320 LAKE SHORE DR, WACO, TX, 76708

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasLowest tier among peers1,167 rated homes · average 2.8★
  • Mc Lennan CountyLowest tier among peers17 rated homes · average 2.2★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs TX avg
  • StaffingCan add or remove a star3★+0.9 vs TX avg
  • Quality measuresCan add or remove a star3★−0.8 vs TX avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above 69% of peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 15% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.39hrsAbove 62% of peersTX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.33hrsAbove only 35% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better53%Above only 44% of peersTX avg51%RN turnover17%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$135,984Above only 13% of peersTX avg$55,368Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
49citations
10inspection dates
1actual harm (G–I)
7immediate jeopardy (J–L)
Dec 11, 2025most recent

Citations by monthFeb 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 11, 20251 citationCycle 1worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 12, 2025
May 10, 20252 citationsCycle 1worst J · immediate jeopardy$23,593
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareJ · isolatedCorrected May 11, 2025
  2. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsJ · isolatedCorrected May 11, 2025
Feb 20, 20257 citationsCycle 1worst F · no actual harm
  1. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsE · patternCorrected Mar 14, 2025
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Mar 14, 2025
  3. 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.Nutrition and DietaryF · widespreadCorrected Mar 14, 2025
  4. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryE · patternCorrected Mar 14, 2025
  5. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsE · patternCorrected Mar 14, 2025
  6. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 14, 2025
  7. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Mar 14, 2025
Sep 10, 20241 citationCycle 2worst E · no actual harm
  1. 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.Pharmacy ServiceE · patternCorrected Sep 11, 2024
Aug 21, 20242 citationsCycle 2worst D · no actual harm
  1. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 5, 2024
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 5, 2024
Jun 29, 20241 citationCycle 2worst E · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jun 30, 2024
May 16, 20241 citationCycle 2worst E · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jun 10, 2024
Dec 16, 202332 citationsCycle 2worst L · immediate jeopardy$83,814
  1. 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.Resident RightsD · isolatedCorrected Jan 12, 2024
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jan 12, 2024
  3. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Jan 12, 2024
  4. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Jan 12, 2024
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jan 12, 2024
  6. F690Provide 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 CareD · isolatedCorrected Jan 12, 2024
  7. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jan 12, 2024
  8. F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Jan 12, 2024
  9. 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.Nursing and Physician ServicesK · patternCorrected Jan 12, 2024
  10. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jan 12, 2024
  11. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jan 12, 2024
  12. 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.Pharmacy ServiceE · patternCorrected Jan 12, 2024
  13. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 12, 2024
  14. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationL · widespreadCorrected Jan 12, 2024
  15. 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.AdministrationD · isolatedCorrected Jan 12, 2024
  16. 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.AdministrationD · isolatedCorrected Jan 12, 2024
  17. F926Have policies on smoking.EnvironmentalE · patternCorrected Jan 12, 2024
  18. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Jan 12, 2024
  19. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Jan 12, 2024
  20. F656Develop 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 PlanningE · patternCorrected Jan 12, 2024
  21. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jan 12, 2024
  22. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Jan 12, 2024
  23. F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationK · patternCorrected Jan 12, 2024
  24. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Jan 12, 2024
  25. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jan 12, 2024
  26. F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected Jan 12, 2024
  27. F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationF · widespreadCorrected Jan 12, 2024
  28. F880Provide and implement an infection prevention and control program.Infection ControlK · patternCorrected Jan 12, 2024
  29. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jan 12, 2024
  30. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jan 12, 2024
  31. 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.Resident RightsD · isolatedCorrected Jan 12, 2024
  32. 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.Resident RightsD · isolatedCorrected Jan 12, 2024
Jun 26, 20231 citationCycle 3worst K · immediate jeopardy$28,577
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Jun 27, 2023
Feb 2, 20231 citationCycle 3worst D · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Feb 9, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.39hrsAbove 62% of peers−0.01 vs TX avg
  • Registered nursesRN hours only0.33hrsAbove only 35% of peers−0.11 vs TX avg
  • Licensed practical nursesLPN hours1.00hrs
  • Nurse aidesCNA hours2.06hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.87hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better53%Above only 44% of peersTX avg 51%
  • RN turnoverRegistered nurses only17%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy151 certified beds · ~121 residents a day80%Above 75% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $135,984In fines
  • 3Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above only 13% of peersFewer fines than 13% of rated homes in Texas

Actions on record

  1. May 10, 2025Civil money penalty$23,593
  2. Dec 16, 2023Civil money penalty$83,814
  3. Jun 26, 2023Civil money penalty$28,577

Ownership

As filed with CMS

Structure

Ownership type
Government - Hospital district
Chain
Eduro Healthcare37 facilities in the chain2.3★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Fannin County Hospital Authority
  • Clark Sanderson
Operational or managerial control
  • Waco Nursing and Rehab Center LLC
  • Michael Bewsey
  • Theresa Sheddy
Corporate directors
  • Theresa Sheddy
Corporate officers
  • Clark Sanderson

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 675438 · 2320 LAKE SHORE DR, WACO, TX, 76708.
  • Percentiles compare this facility with every rated nursing home in Texas and Mc Lennan County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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