Spring Oaks Nursing & Rehab: Immediate Harm Violations TX
LAMPASAS, TX - Federal inspectors found immediate jeopardy conditions at Lily Springs Rehabilitation and Healthcare Center after staff failed to provide cardiopulmonary resuscitation to a resident, marking one of the most serious violations possible in nursing home care.
Immediate Jeopardy: CPR Protocol Breakdown
The March 3, 2025 inspection revealed a critical failure in the facility's emergency response protocols when staff did not provide CPR to a resident designated as "full code," meaning they should receive all life-saving measures including chest compressions and artificial ventilation during cardiac arrest.
The violation carried an "immediate jeopardy" classification - the most severe level possible - indicating conditions that posed immediate threat to resident health and safety. This designation is reserved for situations where regulatory violations have caused or are likely to cause serious injury, harm, impairment or death.
The inspection found confusion among staff regarding residents' code status documentation, which determines whether emergency interventions like CPR should be performed. Staff members were unable to accurately identify which residents had Do Not Resuscitate (DNR) orders versus those designated for full resuscitation efforts.
"The facility failed to ensure Resident #1 was provided CPR," according to the inspection report, which noted systemic problems with how advance directives and resuscitation preferences were documented and communicated to staff.
Medical Significance of CPR Protocol Failures
CPR protocols represent one of the most time-sensitive aspects of nursing home care. During cardiac arrest, brain cells begin dying within 4-6 minutes without oxygen circulation. Each minute of delay reduces survival chances by approximately 10 percent, making immediate recognition and response critical.
For residents designated as "full code," nursing home staff must initiate CPR immediately upon discovering cardiac arrest while simultaneously calling emergency medical services. The intervention involves chest compressions at a rate of 100-120 per minute and rescue breathing to maintain blood circulation to vital organs until advanced medical care arrives.
The failure to provide CPR when medically indicated represents a fundamental breakdown in emergency care protocols. In nursing homes, where residents often have multiple chronic conditions affecting cardiovascular health, clear documentation and staff understanding of code status becomes even more critical for appropriate care delivery.
The Centers for Medicare & Medicaid Services requires nursing homes to honor residents' wishes regarding life-sustaining treatments while ensuring staff can quickly access and understand these preferences during emergencies. When this system fails, residents may not receive care consistent with their documented preferences and medical needs.
Medication Management Failures Compound Safety Concerns
Beyond the CPR incident, inspectors identified significant medication management violations affecting multiple residents. The facility failed to ensure proper pharmaceutical services, specifically regarding hospital discharge medications for a resident with serious respiratory and cardiac conditions.
One resident with chronic respiratory failure, congestive heart failure, COPD, diabetes, and liver cirrhosis did not receive prescribed antibiotics Levofloxacin and Metronidazole for eight days after hospital discharge. The hospital had ordered these medications to treat infections and potentially address lung lesions, but facility staff failed to enter the orders into their system upon admission.
The attending nurse practitioner confirmed the resident should have received these antibiotics immediately upon facility admission. "The NP stated Resident #2 did not receive the Levofloxacin and Metronidazole when he admitted to the facility," according to the inspection report. The medications were not started until a different nurse noticed the oversight over a week later.
This type of medication reconciliation failure poses serious risks for residents with complex medical conditions. Antibiotic delays can allow infections to worsen, potentially leading to sepsis, organ failure, or other life-threatening complications. For residents with compromised immune systems or multiple chronic conditions, missing critical medications during care transitions represents a significant safety threat.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Lily Springs Rehabilitation and Healthcare Center in Lampasas, TX was cited for violations during a health inspection on March 3, 2025.
This designation is reserved for situations where regulatory violations have caused or are likely to cause serious injury, harm, impairment or death.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.