Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Lily Springs Rehabilitation and Healthcare Center
Lampasas, TX · 116 certified beds · Last Life Safety survey May 5, 2025
CMS Certification Number 455889 · first certified July 1990
Ownership
Operated by NEXION HEALTH · For profit - Individual
- Ownership changed March 1, 2020 (change of ownership)from SPRING OAKS NURSING AND REHABILITATION LP
Position within TX
12 citations — more than 74% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to July 2026), and past the point by which nine in ten TX facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 12 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 30, 2022 | 6 |
| January 31, 2024 | 1 |
| May 5, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-05-05 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2024-01-31 |
| K-0900 | Meet Health Care Facilities Code mechanical requirements. | 1 | 2022-11-30 |
| K-0281 | Install proper backup exit lighting. | 1 | 2022-11-30 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2025-05-05 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2025-05-05 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2022-11-30 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2022-11-30 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 2
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 5, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (May 30, 2025) |
January 31, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 23, 2024) |
November 30, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 23, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 23, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 23, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 23, 2023) |
| K-0900 | Meet Health Care Facilities Code mechanical requirements. | Deficient, Provider has date of correction (June 23, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 23, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.