Lily Springs Rehabilitation And Healthcare Center
Lily Springs Rehabilitation and Healthcare Center in Lampasas, TX — inspection on March 3, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with RN C on [DATE] at 1:03 PM, she stated she was trained on [DATE] with the ADON over care plans. RN C stated she trained on making sure care plans were updated immediately when there was a change or change in condition. RN C stated any nurse could update the care plan and the DON would be responsible to make sure the care plans were correct.
During an interview with LVN D on [DATE] at 1:20 PM, she stated she was trained on [DATE] on care plans with the DON. LVN D stated care plans could be updated by any nurse and would need to be updated immediately. LVN D stated when a code status changed it would need to be updated immediately.
During an interview with LVN E on [DATE] at 1:29 PM, stated the CCS trained her on [DATE] over care plans. LVN E stated care plans were updated immediately, and any nurse could update. LVN E stated the care plans would be checked by the DON.
During an interview with the DON on [DATE] at 2:30 PM, she stated she received her care plan training on care plans on [DATE] with the CCS.
The DON stated there was not one person responsible for updating care plans and all nursing staff could update or implement.
The DON stated care plans would be updated immediately at the change or change in condition.
The DON would be checking for accuracy on care plans and it also could be delegated to a nurse.
The DON stated all nursing staff completed their care plan training on [DATE] and any new hires would receive their care plan training at new hire orientation.
During an interview with the ADM on [DATE] at 2:45 PM, stated she completed her in service on [DATE] with the CCS over care plans.
The ADM stated all nursing staff were trained on care plans as of [DATE].
The ADM stated all nursing staff were able up implement and update care plans.
The ADM stated the DON or designee would be responsible for making sure the care plans were correct.
The ADM was informed the Immediate Jeopardy was removed on [DATE] at 3:11 PM.
The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
455889
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 455889 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lily Springs Rehabilitation and Healthcare Center 901 Central Texas Expwy Lampasas, TX 76550
During an interview with RN C on [DATE] at 1:03 PM, she stated she was trained on [DATE] with the ADON over Advanced Directives. RN C stated the training was over code status and where you can find the code status in PCC. RN C stated the code status could also be found in the black binder at the nurse's station.
During an interview with LVN D on [DATE] at 1:20 PM, she stated she was trained on [DATE] on advanced directives with the DON. LVN D stated she was trained on the location of finding the code status and making sure the code status was updated. LVN D stated code status would be located in the black binder at the nurse's station and in PCC .
During an interview with LVN E on [DATE] at 1:29 PM, she stated the CCS trained her on [DATE] over advanced directives.
She was in serviced on knowing the difference between DNR and full code. LVN knew code status was able to be located in PCC and in the black binder at the nurse's station.
During an interview with Med Tech F on [DATE] at 1:40 PM, she stated she completed the training on Advanced Directives on [DATE] with the ADON.
Med Tech F stated she was trained on finding the code status.
Med Tech F stated the code status could be found in PCC and in the black binder at the nurse's station.
During an interview with CNA G on [DATE] at 1:55 PM, she stated she completed the code states training on [DATE] with the ADON. CNA G stated the training was on the location of finding the code status. CNA G stated the code status could be located in the black binder at the nurse's station and in PCC.
During an interview with CNA H on [DATE] at 2:00 PM, he stated he was trained on the code status on [DATE] with the ADON. CNA H stated he was trained on how to find the code status in PCC. CNA H stated the code status could also be found in the black binder at the nurse's station.
During an interview with Med Tech I on [DATE] at 2:05 PM, he stated he was trained on the code status on [DATE] with the DON.
Med Tech I stated he learned where to find the code status at the nurse's station in the black binder.
Med Tech I stated he also learned where to find the code status in PCC.
455889
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 455889 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lily Springs Rehabilitation and Healthcare Center 901 Central Texas Expwy Lampasas, TX 76550