Lake Shore Village Healthcare Center

F-F580

While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of

the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 675438

F-F692 - Failure to Maintain Acceptable Parameters of Nutritional Status

Facility Date IJ Identified: 5-8-25

Date Plan of Removal Implemented: 5-8-25

Person Responsible for Oversight: Administrator/Designee

Immediate Actions Taken to Remove the Immediate Threat

1. Resident #1 (Affected Resident):

Upon identification of the issue, Resident #1 no longer resides in the facility.

2. Identification of At-Risk Residents (Facility-Wide Review):

DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends on 5-8-25.

6 residents were identified with low or declining intake (25% or less) and were immediately evaluated by nursing. NP/MD and RP notifications initiated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 675438 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675438 B. Wing 05/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Care plans updated accordingly by DON/Designee.

Level of Harm - Immediate No other residents with undetected weight loss jeopardy to resident health or safety No other resident with undetected significant change that required notification.

Residents Affected - Some 3. System Correction:

Note: The nursing home is DON/ Designee will in-service Licensed nursing/ licensed agency staff immediately re-educated and disputing this citation. directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations . This will be added to licensed nurses' general orientation for new hires.

DON/ Designee will in-service CNAs/Agency CNA immediately re-educated and directed to notify charge nurse of missed meals or poor intake (<25%), accurate documentation and communication expectations .

This will be added to CNAs general orientation for new hires.

Mandatory in-services will be completed 5/9/25 with all current and oncoming nursing staff prior to start of shift worked.

Competency for License staff and CNAs/Agency CNAs validation conducted on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses/CNAs general orientation for new hires.

Administrator was in-serviced on department head meal manager schedule and details on 5/8/25 by Texas Area President.

Department Heads will be in-serviced by administrator on meal manager requirements .

4. Administrative Oversight/Monitoring:

DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for 30 days and then weekly for 4 weeks to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool.

Any issues will be reported to the QAPI Committee meeting monthly.

Ad hoc QAPI to review the deficiency and the process for POR will be completed 5/9/25.

5. Completion Date: 5/9/25

POR monitoring as above in