Lily Springs Rehabilitation and Healthcare Center
901 Central Texas Expwy
Lampasas, TX, 76550
5125568827
CCN: 455889
1
Overall1
Health3
Staffing2
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
OIG Federal Exclusion Matches (2)
This facility's name matches one or more entities on the OIG List of Excluded Individuals/Entities (LEIE). Excluded parties are prohibited from participation in Medicare and Medicaid programs.
AMAZON HEALTH CENTER, INC
1128b8
Excluded 2010-01-20
SAS HEALTHCARE, INC
1128a1
Excluded 2020-07-20
Ownership
| Name | Role | % |
|---|---|---|
| NEXION HEALTH OF OHI INC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| NEXION HEALTH, INC. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| BOLT, BRETTON | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| KIRLEY, FRANCIS | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| NEXION HEALTH LEASING, INC. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| HERDRICH, WILLIAM | CORPORATE DIRECTOR | NOT APPLICABLE |
| KIRLEY, FRANCIS | CORPORATE DIRECTOR | NOT APPLICABLE |
| LEE, BRIAN | CORPORATE DIRECTOR | NOT APPLICABLE |
| RINER, MEERA | CORPORATE DIRECTOR | NOT APPLICABLE |
| LEE, BRIAN | CORPORATE OFFICER | NOT APPLICABLE |
| RINER, MEERA | CORPORATE OFFICER | NOT APPLICABLE |
| KIRLEY, FRANCIS | CORPORATE OFFICER | NOT APPLICABLE |
| NEXION HEALTH LEASING, INC. | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| KIRLEY, FRANCIS | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MASSOODI, HOSHEM | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| NEXION HEALTH, INC. | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MASSOODI, HOSHEM | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
Penalties (4)
| Date | Type | Amount |
|---|---|---|
| 2025-04-12 | Fine | $8K |
| 2025-03-03 | Fine | $43K |
| 2024-03-19 | Fine | $35K |
| 2023-05-03 | Fine | $15K |
Health Deficiencies (56)
2026-01-07 · Health
D
F557 · Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
2025-11-26 · Health
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2025-11-19 · Health
D
F557 · Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
2025-08-22 · Health
D
F656 · 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.
2025-07-10 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2025-05-05 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F741 · Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2025-04-12 · Health
D
F580 · 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.
2025-03-03 · Health
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
E
F839 · Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
J
F678 · Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
J
F656 · 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.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2024-10-08 · Health
D
F761 · 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.
E
F620 · Resident Rights Deficiencies
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.
2024-08-21 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F761 · 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.
D
F656 · 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.
2024-07-19 · Health
D
F656 · 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.
2024-06-13 · Health
D
F688 · Quality of Life and Care Deficiencies
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.
E
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
G
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-04-04 · Health
E
F761 · 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.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
G
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-03-19 · Health
K
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
2024-01-31 · Health
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F761 · 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.
D
F758 · Pharmacy Service Deficiencies
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.
E
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
E
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F656 · 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.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F637 · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
E
F584 · 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.
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-07-29 · Health
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
2023-05-03 · Health
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2022-11-30 · Health
E
F947 · Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F814 · Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F806 · 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.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
D
F761 · 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.
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.65
RN Hrs/Resident/Day0.54
0.50
LPN Hrs/Resident/Day0.81
0.86
CNA Hrs/Resident/Day2.33
2.29
PT Hrs/Resident/Day0.12
0.07
Data as of 2026-03-01