Lakeshore Village Nursing And Rehabilitation
LAKESHORE VILLAGE NURSING AND REHABILITATION in WACO, TX — inspection on May 10, 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
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.
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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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.