Map showing the location of Lily Springs Rehabilitation and Healthcare Center in Lampasas, Texas
901 Central Texas Expwy, Lampasas, TX, 76550

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasLowest tier among peers1,167 rated homes · average 2.8★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs TX avg
  • StaffingCan add or remove a star3★+0.9 vs TX avg
  • Quality measuresCan add or remove a star2★−1.8 vs TX avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above 69% of peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 4% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.65hrsAbove 79% of peersTX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.50hrsAbove 73% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better59%Above only 29% of peersTX avg51%RN turnover63%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$100,728Above only 17% of peersTX avg$55,368Fines · denials4 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
56citations
18inspection dates
2actual harm (G–I)
5immediate jeopardy (J–L)
Nov 26, 2025most recent

Citations by monthNov 2022 – Nov 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Nov 26, 20252 citationsCycle 1worst D · no actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Dec 5, 2025
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 5, 2025
Nov 19, 20251 citationCycle 1worst D · no actual harm
  1. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Dec 5, 2025
Aug 22, 20251 citationCycle 1worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 18, 2025
Jul 10, 20251 citationCycle 1worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 11, 2025
May 5, 20257 citationsCycle 1worst J · immediate jeopardy
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 6, 2025
  2. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected May 6, 2025
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected May 6, 2025
  4. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 6, 2025
  5. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 6, 2025
  6. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected May 6, 2025
  7. F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and CareE · patternCorrected May 6, 2025
Apr 12, 20251 citationCycle 1worst D · no actual harm$8,281
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Apr 13, 2025
Mar 3, 20256 citationsCycle 1worst J · immediate jeopardy$42,563
  1. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Mar 4, 2025
  2. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareJ · isolatedCorrected Mar 4, 2025
  3. F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationE · patternCorrected Mar 4, 2025
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 4, 2025
  5. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningJ · isolatedCorrected Mar 4, 2025
  6. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 4, 2025
Oct 8, 20242 citationsCycle 2worst E · no actual harm
  1. F620Not 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.Resident RightsE · patternCorrected Nov 1, 2024
  2. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Nov 1, 2024
Aug 21, 20243 citationsCycle 2worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Sep 6, 2024
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 6, 2024
  3. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Sep 6, 2024
Jul 19, 20241 citationCycle 2worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Aug 8, 2024
Jun 13, 20243 citationsCycle 2worst G · actual harm
  1. F688Provide 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.Quality of Life and CareD · isolatedCorrected Jul 14, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsG · isolatedCorrected Jul 14, 2024
  3. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Jul 14, 2024
Apr 4, 20244 citationsCycle 2worst G · actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsG · isolatedCorrected Apr 5, 2024
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 5, 2024
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 5, 2024
  4. F761Ensure 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.Pharmacy ServiceE · patternCorrected Apr 5, 2024
Mar 19, 20241 citationCycle 2worst K · immediate jeopardy$35,363
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareK · patternCorrected Apr 12, 2024
Jan 31, 202411 citationsCycle 2worst E · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Mar 8, 2024
  2. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Mar 8, 2024
  3. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Mar 8, 2024
  4. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 8, 2024
  5. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Mar 8, 2024
  6. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Mar 8, 2024
  7. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Mar 8, 2024
  8. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Mar 8, 2024
  9. F584Honor 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 RightsE · patternCorrected Mar 8, 2024
  10. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Mar 8, 2024
  11. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 8, 2024
Jul 29, 20231 citationCycle 3worst D · no actual harm
  1. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Aug 16, 2023
May 3, 20231 citationCycle 3worst J · immediate jeopardy$14,521
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected May 4, 2023
Feb 13, 20231 citationCycle 3worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 18, 2023
Nov 30, 20229 citationsCycle 3worst E · no actual harm
  1. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Dec 27, 2022
  2. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Dec 27, 2022
  3. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Dec 27, 2022
  4. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryE · patternCorrected Dec 27, 2022
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 27, 2022
  6. F814Dispose of garbage and refuse properly.Nutrition and DietaryE · patternCorrected Dec 27, 2022
  7. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Dec 27, 2022
  8. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 27, 2022
  9. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Dec 27, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.65hrsAbove 79% of peers+0.25 vs TX avg
  • Registered nursesRN hours only0.50hrsAbove 73% of peers+0.06 vs TX avg
  • Licensed practical nursesLPN hours0.86hrs
  • Nurse aidesCNA hours2.29hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.51hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better59%Above only 29% of peersTX avg 51%
  • RN turnoverRegistered nurses only63%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy116 certified beds · ~63 residents a day54%Above only 25% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $100,728In fines
  • 4Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above only 17% of peersFewer fines than 17% of rated homes in Texas

Actions on record

  1. Apr 12, 2025Civil money penalty$8,281
  2. Mar 3, 2025Civil money penalty$42,563
  3. Mar 19, 2024Civil money penalty$35,363
  4. May 3, 2023Civil money penalty$14,521

Ownership

As filed with CMS

Structure

Ownership type
For profit - Individual
Chain
Nexion Health52 facilities in the chain2.4★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Nexion Health of Ohi INC
Indirect owners (5%+)
  • Nexion Health Leasing, INC.
  • Nexion Health, INC.
  • Bretton Bolt
  • Francis Kirley
Operational or managerial control
  • Nexion Health Leasing, INC.
  • Nexion Health, INC.
  • Francis Kirley
  • Hoshem Massoodi
Corporate directors
  • William Herdrich
  • Francis Kirley
  • Brian Lee
  • Meera Riner
Corporate officers
  • Francis Kirley
  • Brian Lee
  • Meera Riner
Managing employees
  • Hoshem Massoodi

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 455889 · 901 Central Texas Expwy, Lampasas, TX, 76550.
  • Percentiles compare this facility with every rated nursing home in Texas and Lampasas County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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