Lily Springs Rehabilitation And Healthcare Center

Penalties

• Apr 12, 2025 — Fine ($8,281)
• Mar 3, 2025 — Fine ($42,563)
• Mar 19, 2024 — Fine ($35,363)

Inspection findings

1. May 19, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 19, 2026 · CMS health inspection

2. Jan 7, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0557 Resident Rights Deficiencies

     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

     Corrected Jan 31, 2026 · CMS health inspection

3. Nov 26, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Dec 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Dec 5, 2025 · CMS health inspection

4. Nov 19, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0557 Resident Rights Deficiencies

     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

     Corrected Dec 5, 2025 · CMS health inspection

5. Aug 22, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Sep 18, 2025 · CMS health inspection

6. Jul 10, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 11, 2025 · CMS health inspection

7. May 5, 2025 Health · 12 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected May 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected May 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 6, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected May 6, 2025 · CMS health inspection

   • Serious Scope/severity J

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 6, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0741 Quality of Life and Care Deficiencies

     Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

     Corrected May 6, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected May 30, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected May 30, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 30, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected May 30, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected May 30, 2025 · CMS fire safety

8. Apr 12, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Apr 13, 2025 · CMS health inspection

9. Mar 3, 2025 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 4, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 4, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0839 Administration Deficiencies

     Employ staff that are licensed, certified, or registered in accordance with state laws.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Mar 4, 2025 · CMS health inspection

10. Oct 8, 2024 Health · 2 findings
    • Not serious Scope/severity E Complaint

      F0620 Resident Rights Deficiencies

      Not 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.

      Corrected Nov 1, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      Ensure 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.

      Corrected Nov 1, 2024 · CMS health inspection

11. Aug 21, 2024 Health · 3 findings
    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      Ensure 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.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Sep 6, 2024 · CMS health inspection

12. Jul 19, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Aug 8, 2024 · CMS health inspection

13. Jun 13, 2024 Health · 3 findings
    • Serious Scope/severity G Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Jul 14, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0677 Quality of Life and Care Deficiencies

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

      Corrected Jul 14, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0688 Quality of Life and Care Deficiencies

      Provide 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.

      Corrected Jul 14, 2024 · CMS health inspection

14. Apr 4, 2024 Health · 4 findings
    • Serious Scope/severity G Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Apr 5, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0677 Quality of Life and Care Deficiencies

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

      Corrected Apr 5, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Apr 5, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0761 Pharmacy Service Deficiencies

      Ensure 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.

      Corrected Apr 5, 2024 · CMS health inspection

15. Mar 19, 2024 Health · 1 finding
    • Serious Scope/severity K Complaint

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Apr 12, 2024 · CMS health inspection

16. Jan 31, 2024 Health · 12 findings
    • Not serious Scope/severity E

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0584 Resident Rights Deficiencies

      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.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0637 Resident Assessment and Care Planning Deficiencies

      Assess the resident when there is a significant change in condition

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0677 Quality of Life and Care Deficiencies

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

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0725 Nursing and Physician Services Deficiencies

      Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      Implement 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.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      Ensure 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.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0919 Environmental Deficiencies

      Make sure that a working call system is available in each resident's bathroom and bathing area.

      Corrected Mar 8, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Aug 23, 2024 · CMS fire safety

17. Nov 30, 2022 Health · 15 findings
    • Not serious Scope/severity D

      F0644 Resident Assessment and Care Planning Deficiencies

      Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      Ensure 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.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0804 Nutrition and Dietary Deficiencies

      Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0806 Nutrition and Dietary Deficiencies

      Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0814 Nutrition and Dietary Deficiencies

      Dispose of garbage and refuse properly.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0947 Nursing and Physician Services Deficiencies

      Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

      Corrected Dec 27, 2022 · CMS health inspection

    • Not serious Scope/severity E

      K0281 Egress Deficiencies

      Install proper backup exit lighting.

      Corrected Jun 23, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Jun 23, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Jun 23, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Jun 23, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0900 Miscellaneous Deficiencies

      Meet Health Care Facilities Code mechanical requirements.

      Corrected Jun 23, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0923 Gas, Vacuum, and Electrical Systems Deficiencies

      Have proper medical gas storage and administration areas.

      Corrected Jun 23, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BOLT, BRETTON — 5% or greater indirect ownership interest, since 03/01/2020
• HERDRICH, WILLIAM — corporate director, NOT APPLICABLE, since 03/01/2020
• KIRLEY, FRANCIS — operational/managerial control, NOT APPLICABLE, since 03/01/2020
• KIRLEY, FRANCIS — 5% or greater indirect ownership interest, since 03/01/2020
• KIRLEY, FRANCIS — corporate director, NOT APPLICABLE, since 03/01/2020
• KIRLEY, FRANCIS — corporate officer, NOT APPLICABLE, since 03/01/2020
• LEE, BRIAN — corporate director, NOT APPLICABLE, since 03/01/2020
• LEE, BRIAN — corporate officer, NOT APPLICABLE, since 03/01/2020
• MASSOODI, HOSHEM — operational/managerial control, NOT APPLICABLE, since 03/01/2020
• MASSOODI, HOSHEM — w-2 managing employee, NOT APPLICABLE, since 03/01/2020
• RINER, MEERA — corporate officer, NOT APPLICABLE, since 03/01/2020
• RINER, MEERA — corporate director, NOT APPLICABLE, since 03/01/2020
• NEXION HEALTH LEASING, INC. — operational/managerial control, NOT APPLICABLE, since 01/09/2020
• NEXION HEALTH LEASING, INC. — 5% or greater indirect ownership interest, since 01/09/2020
• NEXION HEALTH OF OHI INC — 5% or greater direct ownership interest, 100%, since 01/09/2020
• NEXION HEALTH, INC. — 5% or greater indirect ownership interest, since 01/09/2020
• NEXION HEALTH, INC. — operational/managerial control, NOT APPLICABLE, since 01/09/2020