Federal inspection record · CMS data as of October 1, 2026
Lily Springs Rehabilitation and Healthcare Center
901 Central Texas Exp, Lampasas, TX · (512) 556-8827
- Certified beds
- 116
- Residents per day
- 65
- Ownership
- For-Profit
- Chain
- Nexion Health
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 16, 1990
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Lily Springs Rehabilitation and Healthcare Center carries 164.25 inspection points. That is fewer than 16% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
52 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (6)
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
-
J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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G
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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G
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
-
K
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Resident Rights10E
- E
Keep residents' personal and medical records private and confidential.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Not 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.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- E
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.
Resident Assessment and Care Planning9D
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Assess the resident when there is a significant change in condition
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care8E
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide activities to meet all resident's needs.
- E
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide 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.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pharmacy Service6E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
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.
- E
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.
- D
Implement 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.
- D
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.
Infection Control5E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- E
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation3D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Environmental2E
- E
Have policies on smoking.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Nutrition and Dietary1E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration1E
- E
Employ staff that are licensed, certified, or registered in accordance with state laws.
Nursing and Physician Services1E
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspection history
2026-06-24
11 health deficiencies · 1 fire-safety deficiencies
Top issue: Resident Rights (5 deficiencies)
2025-05-05
18 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-01-31
23 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 13 min of nursing staff time a day, 27 min of it from a registered nurse.
This home
4 h 13 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 57% of nursing staff and 44% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$86,207 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-04-12 | Fine | $8,281 |
| 2025-03-03 | Fine | $42,563 |
| 2024-03-19 | Fine | $35,363 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.7 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days3.8 pts worse | 5.8 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine8.2 pts worse | 88.2% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.4 pts worse | 92.6% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.1 pts worse | 3.3% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.3 pts better | 0.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.8 pts worse | 5.7% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication3.7 pts worse | 21.5% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.6 pts better | 9.2% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened16.1 pts worse | 29.0% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased13.6 pts worse | 29.4% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladderAbout the same | 0.3% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infectionAbout the same | 0.8% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.7 pts better | 11.8% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.6 pts better | 2.1% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine29.1 pts worse | 59.6% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit8.5 pts worse | 20.7% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine14.3 pts worse | 71.1% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission10.4 pts worse | 35.9% | 25.5% | 23.4% |
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Who owns and runs it
17 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Nexion Health Of Ohi Inc | 5% Or Greater Direct Ownership Interest · Organization | 100% | 31 facilities |
| Bolt, Bretton | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 30 facilities |
| Herdrich, William | Corporate Director · Individual | 0% | 32 facilities |
| Kirley, Francis | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 50 facilities |
| Kirley, Francis | Corporate Director · Individual | 0% | 50 facilities |
| Kirley, Francis | Corporate Officer · Individual | 0% | 50 facilities |
| Kirley, Francis | Operational/Managerial Control · Individual | 0% | 50 facilities |
| Lee, Brian | Corporate Director · Individual | 0% | 45 facilities |
| Lee, Brian | Corporate Officer · Individual | 0% | 45 facilities |
| Massoodi, Hoshem | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Massoodi, Hoshem | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Nexion Health Leasing, Inc. | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 33 facilities |
| Nexion Health Leasing, Inc. | Operational/Managerial Control · Organization | 0% | 33 facilities |
| Nexion Health, Inc. | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 33 facilities |
| Nexion Health, Inc. | Operational/Managerial Control · Organization | 0% | 33 facilities |
| Riner, Meera | Corporate Director · Individual | 0% | 46 facilities |
| Riner, Meera | Corporate Officer · Individual | 0% | 46 facilities |
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Fire safety
7 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke5E
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Install an approved automatic sprinkler system.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Miscellaneous1D
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems1D
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
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Other homes nearby
-
Lampasas Nursing and Rehabilitation Center
Lampasas, TX · Diversicare Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 47 min
- Fines
- $24,529
-
Caraday Of Lampasas
Lampasas, TX · Caraday Healthcare
★★★★★- Worst citation, 3 yrs
- H
- Nursing / resident / day
- 3 h 15 min
- Fines
- $13,072
-
Copperas Cove Nursing & Rehabilitation
Copperas Cove, TX · Gulf Coast Ltc Partners
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 7 min
- Fines
- $24,242