Lily Springs Rehabilitation and Healthcare Center
Open-data reference.
Lily Springs Rehabilitation and Healthcare Center is a for profit - individual facility in Lampasas, TX with 116 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $101K.
901 Central Texas Expwy, Lampasas, TX 76550
Phone: 5125568827
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 455889
- Ownership
- For profit - Individual
- Provider Type
- Medicare and Medicaid
- Beds
- 116
- Residents
- 63
- In Hospital
- No
- County
- Lampasas
- Last Inspection
- May 5, 2025
Staffing Data
- RN Hours
- 0.50 (nat'l avg: 0.68)
- LPN Hours
- 0.86
- CNA Hours
- 2.29
- Total Nursing Hours
- 3.65 (nat'l avg: 3.89)
- PT Hours
- 0.07
- Nursing Turnover
- 58.9%
- RN Turnover
- 62.5%
What the CMS Record Reveals About Lily Springs Rehabilitation and Healthcare Center
Lily Springs Rehabilitation and Healthcare Center operates 116 certified beds in Lampasas, TX with approximately 63 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (3★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 7 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 4 penalties totaling $101K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.65 total nursing hours per resident day (national average 3.89), with RN coverage at 0.50 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Individual" ownership and operating as a "Medicare and Medicaid" provider, Lily Springs Rehabilitation and Healthcare Center falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 58.9%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 5, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Dec 5, 2025
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Category: Resident Rights Deficiencies
Corrected: Dec 5, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 18, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 11, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 6, 2025
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2025
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: May 6, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 6, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 6, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: May 6, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Apr 13, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Mar 4, 2025
Employ staff that are licensed, certified, or registered in accordance with state laws.
Category: Administration Deficiencies
Corrected: Mar 4, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Mar 4, 2025
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 4, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 4, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Mar 4, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 1, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Nov 1, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 6, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 6, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 6, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 8, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 14, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 14, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jul 14, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 5, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 5, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 5, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Apr 5, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 12, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Mar 8, 2024
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Mar 8, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 8, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 8, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 8, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 8, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 8, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 8, 2024
Assess the resident when there is a significant change in condition
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 8, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Mar 8, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Mar 8, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Aug 16, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 4, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Feb 18, 2023
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Dec 27, 2022
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 27, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 27, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 39.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.3% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.1% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.1% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 88.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 40.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 36.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 22.8% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 95.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 37.8% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.1% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 16.9% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 8.8% | Yes |
Penalty History 4 penalties totaling $101K
| Date | Type | Amount |
|---|---|---|
| Apr 12, 2025 | Fine | $8K |
| Mar 3, 2025 | Fine | $43K |
| Mar 19, 2024 | Fine | $35K |
| May 3, 2023 | Fine | $15K |
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Frequently Asked Questions
What is the overall CMS rating for Lily Springs Rehabilitation and Healthcare Center?
What are the staffing levels at Lily Springs Rehabilitation and Healthcare Center?
How many beds does Lily Springs Rehabilitation and Healthcare Center have?
Does Lily Springs Rehabilitation and Healthcare Center have any deficiencies on record?
Has Lily Springs Rehabilitation and Healthcare Center received any fines or penalties?
Who owns Lily Springs Rehabilitation and Healthcare Center?
When was Lily Springs Rehabilitation and Healthcare Center last inspected?
What quality measures are tracked for Lily Springs Rehabilitation and Healthcare Center?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.