Lake Village Nursing And Rehabilitation Center
LAKE VILLAGE NURSING AND REHABILITATION CENTER in LEWISVILLE, TX — inspection on September 16, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 09/16/2025 at 3:45 PM, the DON stated each morning staff met and discussed care plans and interventions to put in place.
She stated resident #1 had been at the facility for a long time and received ongoing PASRR services.
She stated she was unaware a positioning wedge was recommended for Resident #1 on 03/04/2025.
She printed Resident #1's PCSP which reflected the recommendation for a repositioning wedge.
She stated page 7 of the PCSP did not reflect any changes to his care plan.
She stated if new needs were identified, they would be documented there.
She stated Resident #1 had his last PCSP meeting on 08/25/2025 and it reflected a repositioning wedge was not needed.
During an interview on 09/16/2025 at 3:55 PM, the Administrator stated after an IDT meeting, staff members discussed any items that needed follow up and he followed up with the MDS Coordinator to ensure the PCSP was complete.
The Administrator stated he was not told Resident #1 needed a positioning wedge or the facility would have already purchased one. He stated it was important for the facility to provide recommended services to ensure the resident's needs were met.During a telephone interview on 09/19/2025 at 4:30 PM, the Habilitation Coordinator stated the repositioning wedge was recommended during the 03/04/2025 interdisciplinary team meeting, because Resident #1 leaned to one side, and she had approved it.
She stated the nursing facility emailed her about the visit from a state surveyor requesting information about Resident #1.
She stated the facility requested an interdisciplinary team meeting and she scheduled a meeting on October 1st to evaluate Resident #1's needs.
Record review of the facility's policy Resident Assessment: PASRR, reviewed 05/2021, reflected It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the state. (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such a level of services, whether the individual requires specialized services for the intellectual disability.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Village Nursing and Rehabilitation Center
169 Lake Park Rd Lewisville, TX 75057
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited LAKE VILLAGE NURSING AND REHABILITATION CENTER in LEWISVILLE, TX for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-09-16.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of LAKE VILLAGE NURSING AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-15.