Lily Springs Rehabilitation And Healthcare Center

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the resident would not be able to call for assistance.During an interview with the ADM on 11/12/2025 at 3:30 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a resident's call light was not within reach, then the resident would not be able to express their needs nor have their needs met. The ADM stated his expectation was for staff members to ensure call lights were within reach prior to exiting the resident's rooms.A record review of the facility's Resident Call System policy, dated October 2022, reflected Resident are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bath facilities and from the floor 4. If the resident has a disability that prevent him/her from making use of the calls system, an alternative means of communication that unable for the resident is provided and documented in the care plan

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lily Springs Rehabilitation and Healthcare Center

901 Central Texas Expwy Lampasas, TX 76550

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents were provided care and services to carry out activities of daily living to maintain personal hygiene for 1 of 7 residents (Resident #2) reviewed for quality of life.The facility failed to provide showers to Resident #2 in compliance with her shower schedule.This deficient practice could place residents at risk of decline in overall health.Findings included:Record review of Resident #2's admission record, dated 11/12/2025, reflected an [AGE] year-old female who was re-admitted to the facility on [DATE REDACTED]. Resident #2 had diagnoses which included: unspecified dementia (memory loss and problems with thinking and reasoning), generalized anxiety disorder (mental health condition characterized by excessive and uncontrollable worry about everyday things), and major depressive disorder (persistent feeling of sadness and loss of interest, making it hard to function in daily life). Record review of Resident #2's Quarterly MDS assessment, dated 09/17/2025, reflected Resident #2 had a BIMS score of 07, which indicated severe cognitive impairment. Resident #2 required substantial/maximal assistance in the areas of toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #2 was dependent in the area of shower/bathe self.Record review of Resident #2's care plan, dated 11/12/2025, reflected Resident #2 was care planned for ADL self-care performance deficit r/t limited mobility and had an intervention of shower/bathe self: dependent.Review of Resident #2's EMR task Shower/Bathe self Prefers: Specify T-TH-Sat evenings dated 11/12/2025, reflected no documentation that Resident #2 received a shower /bath on the following dates: 10/30/2025, 11/01/2025, 11/04/2025, or 11/06/2025During an interview on 11/12/2025 at 09:06 AM, Resident #2 stated she has not received a bath in a while but could not provide dates.During an interview

on 11/12/2025 at 2:30 PM, CNA A stated she was not aware that Resident #2 did receive a shower/bath on

the following dates: 10/30/2025, 11/01/2025, 11/04/2025, or 11/06/2025. CNA A stated that resident's bath/shower schedule was located on the POC in EMR. CNA A stated she was not assigned to Resident #2

on the following dates: 10/30/2025, 11/01/2025, 11/04/2025, or 11/06/2025. CNA A stated that if a resident did not receive scheduled a bath/shower they would smell bad or could have skin breakdown.During an

interview with the ADON on 11/12/2025 at 3:10 PM, the ADON stated CNAs were responsible for giving the residents a bath/shower. The ADON stated if a resident did not receive their scheduled bath/shower they could develop an odor or a skin issue. The ADON stated she expected for all residents to receive a bath/shower as scheduled.During an interview with the ADM on 11/12/2025 at 3:30 PM, the ADM stated

the CNAs were responsible for giving the residents a bath/shower. The ADM stated that residents would develop an odor if they were not receiving a bath/shower per the residents' bath/shower schedule. The ADM stated that he expected for all residents to receive a bath/shower as scheduled.A record review of the facility's ADL Care & Personal Hygiene policy, dated 12/2020, reflected staff provides assistance to residents who need assistance with personal hygiene to prevent an odor problem and to prevent skin breakdown. Procedure All residents are encouraged and responsible for their personal hygiene. Personal hygiene tasks include: washing up, bathing, dressing, mouth care, shaving, and hair care. The amount of hygiene assistance provided to a resident will be discussed with the resident and indicated in his/her Person-Centered Service Plan (PSCP). The PCSP and amount of hygiene assistance given will be reviewed at regular intervals and appropriate changes made on an as needed basis. Independence will be encouraged and supported. If more help is needed than can be provided, alternatives will be explored (e.g. family, home health agency, etc.) .

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet