Health inspection·June 29, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure [NAME] A, Dishwasher C, and DA B wore hairnets and beard restraints when cooking, preparing, or assembling food. This failure could place residents who received meals and/or snacks from the kitchen at risk of foodborne illness due to physical contamination. Findings included: An observation of the dining room on 06/29/24 at 9:58 a.m. revealed [NAME] A walked out of the kitchen and into the dining room. [NAME] A was not wearing a beard restraint. Dishwasher C was also not wearing a hairnet when washing dishes at the dishwashing station in the kitchen. During an interview on 06/29/24 at 10:02 a.m., [NAME] A revealed he was not wearing a beard restraint, but he wore a hair net. [NAME] A stated food service staff were required to wear hairnets once they entered the kitchen. [NAME] A explained only food service staff on the service line and cooks must wear hairnets. [NAME] A stated he was not required to wear a beard restraint. [NAME] A also stated he was trained by the DM on when to wear hairnets. [NAME] A also stated not wearing hairnets and beard restraints could cause residents to find hair in food. During an interview on 06/29/24 at 10:09 a.m., Dishwasher C revealed all food service staff in the kitchen were required to wear hairnets. Dishwasher C stated dishwashers were required to wear hairnets. Dishwasher C also stated she did not wear a hairnet because she was late to work, forgot to grab one, and started working on dishes. Dishwasher C stated residents' health could not be affected by dishwashers not wearing hairnets. Dishwasher C stated when entering the kitchen, staff must wear a hairnet. Dishwasher C stated she received training and was in-serviced on hairnets every three and a half weeks by the DM. An observation of the kitchen on 06/29/24 at 10:16 a.m. revealed DA B was not wearing a hairnet and assembling food at the food service line. During an interview on 06/29/24 at 10:16 a.m., DA B revealed all food service staff in the kitchen were required to wear hairnets when they step into the kitchen. DA B stated there was no reason why she was not wearing a hairnet. DA B also stated not wearing hairnets could cause residents to find (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675438 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2024 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)