Lily Springs Rehabilitation and Healthcare Center
901 Central Texas Expwy, Lampasas, TX 76550 · CCN 455889
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★☆☆☆ 2
- Staffing
- ★★★☆☆ 3
Facility
- Ownership type
- For profit - Individual
- Certified beds
- 116
- Avg residents/day
- 63.0
- Phone
- 5125568827
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-05-05 | 20 | 9.1 | 9.5 | +10.9 worse |
| 2 | 2024-01-31 | 25 | 9.4 | 9.8 | +15.6 worse |
| 3 | 2022-11-30 | 11 | 8.1 | 9.3 | +2.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 3 |
| Quality of life and care | 5 |
| Resident assessment and care planning | 2 |
| Resident rights | 5 |
| Pharmacy service | 1 |
| Administration | 1 |
| Infection control | 3 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.65 | 58.9% |
| RN staffing (reported) | 0.50 | 62.5% |
| Total nurse staffing (adjusted) | 3.96 | — |
Fines & penalties
- Total fines
- $100,728
- Number of fines
- 4
- Number of penalties
- 4
- Payment denials
- 0
Chain
- Chain
- NEXION HEALTH
- Facilities in chain
- 52
- Chain avg overall
- 2.30 / 5
Inspection citations (56)5 immediate jeopardy2 actual harm
- DF0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.2026-01-07 · Health · corrected 2026-01-31
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2025-11-26 · Health · corrected 2025-12-05
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-11-26 · Health · corrected 2025-12-05
Potential for more than minimal harm
- DF0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.2025-11-19 · Health · corrected 2025-12-05
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-08-22 · Health · corrected 2025-09-18
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-07-10 · Health · corrected 2025-07-11
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2025-05-05 · Health · corrected 2025-05-06
Potential for more than minimal harm
- DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2025-05-05 · Health · corrected 2025-05-06
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-05-05 · Health · corrected 2025-05-06
Potential for more than minimal harm
- EF0679Provide activities to meet all resident's needs.2025-05-05 · Health · corrected 2025-05-06
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-05-05 · Health · corrected 2025-05-06
Immediate jeopardy
- EF0741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.2025-05-05 · Health · corrected 2025-05-06
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-05-05 · Health · corrected 2025-05-06
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-04-12 · Health · corrected 2025-04-13
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-03-03 · Health · corrected 2025-03-04
Potential for more than minimal harm
- JF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-03-03 · Health · corrected 2025-03-04
Immediate jeopardy
- JF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2025-03-03 · Health · corrected 2025-03-04
Immediate jeopardy
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-03-03 · Health · corrected 2025-03-04
Potential for more than minimal harm
- EF0839Employ staff that are licensed, certified, or registered in accordance with state laws.2025-03-03 · Health · corrected 2025-03-04
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-03-03 · Health · corrected 2025-03-04
Potential for more than minimal harm
- EF0620Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.2024-10-08 · Health · corrected 2024-11-01
Potential for more than minimal harm
- DF0761Ensure 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.2024-10-08 · Health · corrected 2024-11-01
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-08-21 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0761Ensure 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.2024-08-21 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-08-21 · Health · corrected 2024-09-06
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-07-19 · Health · corrected 2024-08-08
Potential for more than minimal harm
- GF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-06-13 · Health · corrected 2024-07-14
Actual harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-06-13 · Health · corrected 2024-07-14
Potential for more than minimal harm
- DF0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.2024-06-13 · Health · corrected 2024-07-14
Potential for more than minimal harm
- GF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-04-04 · Health · corrected 2024-04-05
Actual harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-04-04 · Health · corrected 2024-04-05
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-04-04 · Health · corrected 2024-04-05
Potential for more than minimal harm
- EF0761Ensure 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.2024-04-04 · Health · corrected 2024-04-05
Potential for more than minimal harm
- KF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-03-19 · Health · corrected 2024-04-12
Immediate jeopardy
- EF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- EF0584Honor 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.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0637Assess the resident when there is a significant change in condition2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0761Ensure 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.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-01-31 · Health · corrected 2024-03-08
Potential for more than minimal harm
- DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2023-07-29 · Health · corrected 2023-08-16
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-05-03 · Health · corrected 2023-05-04
Immediate jeopardy
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- DF0761Ensure 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.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- EF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- EF0814Dispose of garbage and refuse properly.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
- EF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2022-11-30 · Health · corrected 2022-12-27
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| NEXION HEALTH OF OHI INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2020-01-09 |
| NEXION HEALTH LEASING, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2020-01-09 |
| NEXION HEALTH, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2020-01-09 |
| BOLT, BRETTON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2020-03-01 |
| KIRLEY, FRANCIS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2020-03-01 |
| NEXION HEALTH LEASING, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-01-09 |
| NEXION HEALTH, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-01-09 |
| KIRLEY, FRANCIS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-03-01 |
| MASSOODI, HOSHEM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-03-01 |
| HERDRICH, WILLIAM | Individual | CORPORATE DIRECTOR | — | 2020-03-01 |
| KIRLEY, FRANCIS | Individual | CORPORATE DIRECTOR | — | 2020-03-01 |
| LEE, BRIAN | Individual | CORPORATE DIRECTOR | — | 2020-03-01 |
| RINER, MEERA | Individual | CORPORATE DIRECTOR | — | 2020-03-01 |
| KIRLEY, FRANCIS | Individual | CORPORATE OFFICER | — | 2020-03-01 |
| LEE, BRIAN | Individual | CORPORATE OFFICER | — | 2020-03-01 |
| RINER, MEERA | Individual | CORPORATE OFFICER | — | 2020-03-01 |
| MASSOODI, HOSHEM | Individual | W-2 MANAGING EMPLOYEE | — | 2020-03-01 |
Other facilities in Lampasas
| Name | Overall | Beds |
|---|---|---|
| Lampasas Nursing and Rehabilitation Center | ★☆☆☆☆ | 68 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.