Lakeshore Village Nursing And Rehabilitation

Penalties

• May 10, 2025 — Fine ($23,593)
• Dec 16, 2023 — Fine ($83,814)

Inspection findings

1. Apr 22, 2026 Health · 4 findings
   • Not serious Scope/severity E

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected May 4, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected May 4, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 4, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 4, 2026 · CMS health inspection

2. Mar 3, 2026 Health · 1 finding
   • Not serious Scope/severity F Complaint

     F0562 Resident Rights Deficiencies

     Provide immediate access to any resident.

     Corrected Mar 4, 2026 · CMS health inspection

3. Dec 11, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 12, 2025 · CMS health inspection

4. May 10, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected May 11, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected May 11, 2025 · CMS health inspection

5. Feb 20, 2025 Health · 7 findings
   • Not serious Scope/severity E Complaint

     F0557 Resident Rights Deficiencies

     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0803 Nutrition and Dietary Deficiencies

     Ensure 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.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 14, 2025 · CMS health inspection

6. Sep 10, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure 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.

     Corrected Sep 11, 2024 · CMS health inspection

7. Aug 21, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Sep 5, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Sep 5, 2024 · CMS health inspection

8. Jun 29, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 30, 2024 · CMS health inspection

9. May 16, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 10, 2024 · CMS health inspection

10. Dec 16, 2023 Health · 32 findings
    • Not serious Scope/severity D Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0578 Resident Rights Deficiencies

      Honor 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.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0584 Resident Rights Deficiencies

      Honor 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.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0585 Resident Rights Deficiencies

      Honor 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.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0640 Resident Assessment and Care Planning Deficiencies

      Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0655 Resident Assessment and Care Planning Deficiencies

      Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0658 Resident Assessment and Care Planning Deficiencies

      Ensure services provided by the nursing facility meet professional standards of quality.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0679 Quality of Life and Care Deficiencies

      Provide activities to meet all resident's needs.

      Corrected Jan 12, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0690 Quality of Life and Care Deficiencies

      Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0699 Quality of Life and Care Deficiencies

      Provide care or services that was trauma informed and/or culturally competent.

      Corrected Jan 12, 2024 · CMS health inspection

    • Serious Scope/severity K Complaint

      F0726 Nursing and Physician Services Deficiencies

      Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0761 Pharmacy Service Deficiencies

      Ensure 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.

      Corrected Jan 12, 2024 · CMS health inspection

    • Serious Scope/severity K

      F0770 Administration Deficiencies

      Provide timely, quality laboratory services/tests to meet the needs of residents.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0791 Quality of Life and Care Deficiencies

      Provide or obtain dental services for each resident.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0804 Nutrition and Dietary Deficiencies

      Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0810 Nutrition and Dietary Deficiencies

      Provide special eating equipment and utensils for residents who need them and appropriate assistance.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity F Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Jan 12, 2024 · CMS health inspection

    • Serious Scope/severity L Complaint

      F0835 Administration Deficiencies

      Administer the facility in a manner that enables it to use its resources effectively and efficiently.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0838 Administration Deficiencies

      Conduct 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.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0849 Administration Deficiencies

      Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0868 Administration Deficiencies

      Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

      Corrected Jan 12, 2024 · CMS health inspection

    • Serious Scope/severity K

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jan 12, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0926 Environmental Deficiencies

      Have policies on smoking.

      Corrected Jan 12, 2024 · CMS health inspection

Owners and managers (as published by CMS)

• BEWSEY, MICHAEL — operational/managerial control, NOT APPLICABLE, since 09/01/2022
• SANDERSON, CLARK — 5% or greater direct ownership interest, since 04/01/2022
• SANDERSON, CLARK — corporate officer, NOT APPLICABLE, since 10/29/2012
• SHEDDY, THERESA — corporate director, NOT APPLICABLE, since 09/01/2016
• SHEDDY, THERESA — operational/managerial control, NOT APPLICABLE, since 09/01/2016
• FANNIN COUNTY HOSPITAL AUTHORITY — 5% or greater direct ownership interest, since 04/01/2022
• WACO NURSING AND REHAB CENTER LLC — operational/managerial control, NOT APPLICABLE, since 09/01/2022