Complaint Investigation

Lakeshore Village Nursing And Rehabilitation

Q: What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Q: Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

Q: How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

Q: What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WACO, TX, (5) Report new concerns to state authorities.

Q: Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAKESHORE VILLAGE NURSING AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

May 10, 2025 · Waco, TX · 2320 Lake Shore Dr

Citations 2

CMS Rating 1/5

Beds 151

Provider ID 675438

Healthcare Facility

Lakeshore Village Nursing And Rehabilitation

Waco, TX · View full profile →

Inspection Summary

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

FF580

Immediate accurate documentation in nurses note and communication expectations . This will be added to licensed Some shift worked. affected

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.

675438

FF692

Immediate removal and plan of correction. Some affected

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 .

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.

Completion Date: 5/9/25

POR monitoring as above in

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WACO, TX, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAKESHORE VILLAGE NURSING AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

Lakeshore Village Nursing And Rehabilitation

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