Lake Village Nursing and Rehabilitation Center
169 Lake Park Rd, Lewisville, TX 75057 · Denton County · 112 certified beds · avg 77 residents/day · certified since Jan 4, 1996
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$24,585
Fines, last 3 years
2.91
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jan 26, 2024 · F-0880 · triggered by a complaint
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 28, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 5, 2026 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| May 5, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 5, 2026 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| May 5, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 5, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 5, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 5, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 5, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 28, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Nov 28, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 16, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Sep 16, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 6, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Dec 4, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Dec 4, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jan 26, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 26, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Jan 26, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jan 26, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jan 26, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 26, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (7 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 14 | 1 | K ▲ |
| 2025 | 11 | 0 | E |
| 2026 | 8 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $24,585, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jan 26, 2024 | Fine | $24,585 |
| Jan 26, 2024 | Payment Denial | 8 days from Feb 28, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.91 | 3.46 | 3.95 | bottom 18% in Texas; bottom 11% in the U.S. |
| Registered Nurse hours | 0.42 | 0.44 | 0.69 | top 42% in Texas; bottom 25% in the U.S. |
| Weekend total nurse staffing | 2.38 | 3.04 | 3.50 | bottom 9% in Texas; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.20 | 0.34 | 0.48 | bottom 24% in Texas; bottom 13% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.3 | 45.8 | — |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.07, RN 0.44, weekend 2.51. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Eastland Memorial Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2017 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2007 |
| Caretrust GP LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Grand Villa PHX, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Grand Villa PHX, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 08/13/2025 |
| Hernandez, Miguel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2023 |
| Hernandez, Miguel | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Hernandez, Miguel | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2023 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Mall, Allen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2007 |
| Mall, Allen | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2007 |
| Mall, Allen | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Taylor, Stephen | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Verde Villa Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Rambling Oaks Courtyard Extensive Care Community | 3.5 mi | Highland Village, TX | ★★★☆☆ | 3/5 | |
| Hollymead | 3.8 mi | Flower Mound, TX | ★★★☆☆ | 3/5 | |
| Cross Timbers Rehabilitation and Healthcare Center | 4.4 mi | Flower Mound, TX | ★★★☆☆ | 3/5 | |
| Vista Ridge Nursing & Rehabilitation Center | 5.6 mi | Lewisville, TX | ★★★★☆ | 3/5 | |
| Corinth Rehabilitation Suites on the Parkway | 6.2 mi | Corinth, TX | ★☆☆☆☆ | 2/5 | |
| Denton Rehabilitation and Nursing Center | 6.8 mi | Denton, TX | ★★★★☆ | 3/5 | |
| Brookhaven Nursing and Rehabilitation Center | 7.9 mi | Carrollton, TX | ★☆☆☆☆ | 1/5 | abuse |
| Sandy Lake Rehabilitation and Care Center | 8.1 mi | Coppell, TX | ★★☆☆☆ | 2/5 | |
| Lake Forest Village by Purehealth | 8.6 mi | Denton, TX | ★★★★☆ | 3/5 | |
| Mustang Park Therapy and Living Center | 8.7 mi | Carrollton, TX | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675560.