Health inspection·September 16, 2021

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concern. He would then go back to the resident and let them know of the outcome. He reported he would file a grievance for a resident if an expensive item went missing, there was missing laundry, or for an allegation of staff verbal/physical/emotional abuse. He reported he had spoken to Resident #30, and she only had issues with one staff member. He told the resident that the employee would not be assigned her. He was asked if he had any documentation verifying he spoke with the staff member about conduct or whether education was provided. He stated no, it was done verbally and he had no documentation of it. He also reported that he told the Unit Manager that Employee L was not to be assigned to Resident #30. He again stated it was a verbal communication and nothing was documented. The DON was asked if he was aware that Employee L had been assigned to Resident #30 yesterday. He stated, No, I did not. An interview was conducted with Social Services Assistant (SSA) on 9/16/21 at 1:00 PM. She stated grievances could come from family, staff, or residents. She reported that grievances were not always filed for a concern, it depended upon what the resident wanted done. The SSA was asked if a resident reported that a CNA was not doing their duties, would that be a reason to file a grievance? She stated, Yes, I believe that is a reason to fill out grievance. An interview was conducted with [NAME] President of Clinical Services (VP) and the Administrator on 9/16/21 at 3:29 PM. At this time, the VP stated grievances could be reported by staff, residents, or anonymously. Grievances were handled by each department manager and then a resolution was put in place. All resolutions were reported at quality assurance meetings. The VP was asked about education and confirmed that Employee L was the staff member mentioned in the grievance filed in January 2021, and she was provided education at that time. A review of the facility's grievance policy revealed that the objective was to ensure the facility took prompt efforts to resolve any grievance a resident may have. The intent of the grievance process was to support each resident's right to voice grievances, and to ensure that after receiving a complaint/grievance, the facility actively sought a resolution and kept the resident appropriately apprised of its progress toward a resolution. Grievances could be expressed orally to the grievance official or facility staff. The Grievance Officer would offer a written response to the resident or resident representative. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 2 of 5 Printed: 05/28/2026 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 105816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lilac at Bayview, The 161a Marine Street Saint Augustine, FL 32084 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, record review and facility policy and procedure review, the facility failed to maintain essential kitchen equipment in safe operating condition by not ensuring proper maintenance of the low temperature dishwashing machine. Failure to ensure clean and sanitized dishware creates the potential for foodborne illness and infection in vulnerable nursing home residents. This failure had the potential to affect every resident who consumed food from the facility's kitchen. Residents Affected - Many The findings include: An initial tour of the kitchen was conducted on 9/13/21 at at 10:00 AM. The dish machine was not running. Ware washing set up, but all dishes were washed and air drying. Employee D confirmed that all the breakfast dishes were already washed. She stated she documents the temperature of the wash and rinse cycles and the amount of chemical sanitizer in the machine every day for each meal. She provided the log for review. The log was filled in with temperatures of 120'F (degrees Fahrenheit) for both the wash and rinse cycles and 50 parts per million (ppm)of chlorine chemical sanitizer each day. During a second tour of the kitchen dish room on 9/14/2021 at 9:16 AM, Employee B was asked to run the low temperature mechanical dish machine. She ran it and stated the machine has to be run a couple of times to get the machine up to the right temperature (temp). She stated the wash cycle temperature should be 120'F (Fahrenheit) to 140'F. The final rinse cycle should be 120'F to 140'F. The actual temperature for the wash cycle was 100'F and the temperature for the final rinse cycle was 109'F. Employee B was asked to test the chemical sanitizer. She used the wrong test strips to test the dish machine. The Dietary Manager (DM) corrected her and then she tested the machine. The test strip indicated 50 ppm. The DM tested the water with a digital food thermometer, and it read 112'F. She stated she did not know why the machine temperature was not reaching the minimum temperature of 120'F but she would have the maintenance department look at it. She stated they would use paper products until it was fixed. During an interview with Employee D on 09/14/2021 at 11:26 AM, she stated that they did not call the contracted maintenance company for the dish machine or the maintenance department. They just ran the machine several times to allow the water temperature to come up to 120'F. She stated it did reach 120'F. During an interview with the DM on 9/14/2021 at 3:24 PM, she stated that the maintenance representative from the contracted maintenance company for the dish machine was in the kitchen currently and he had told her the machine is working fine and it does not need a heat booster. He told her that what matters is the sanitizer level. She stated she was in disagreement with him, and she told him he needed to fix the machine so that it consistently reaches 120'F at a minimum for both the wash and rinse cycles. During an interview 9/14/2021 at 3:30 PM with the representative from the contracted maintenance company for the dish machine, he stated that the temperature of the water only needs to be between 112'F and 122'F. The sanitizer level is the most important thing. When the minimum temperatures for the wash and rinse cycles were shown to him on a metal plaque applied to the side of the machine, he stated that the water has to be hot. It is a low temperature machine. He confirmed that the plaque read: Minimum temperature wash cycle 120'F. Minimum temperature rinse cycle 120'F. He confirmed the manufacturer of the dish machine had certain specifications for the proper use of this dish machine and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 3 of 5 Printed: 05/28/2026 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 105816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lilac at Bayview, The 161a Marine Street Saint Augustine, FL 32084 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that was what was posted on the plaque. He confirmed that a heat booster could be applied to the machine, and he would call his office to arrange for one. On 9/15/2021 at 11:10 AM the dish machine was run, and the temperature of the water was: 114'F wash cycle and 117'F rinse cycle. Employee E tested the water with a digital thermometer. The gauge on the machine read the same. The water temperature gauge on the pipe at the wall read 130'F. After a few minutes, Employee E came and showed a picture of the thermometer reading 122'F. She asked the dish washer, Employee B, how many loads she put through before it reached 122'F. Employee B told her 2 loads. On 9/16/21 at 10:00 AM the dish machine was observed to be operating. Employee C and another dietary staff member were present in dish room using the dish machine. Employee C was asked to temp the machine with a digital thermometer. The gauge on the machine was reaching 114-115'F. The digital thermometer read 114.9'F and went up to 115'F and then dropped back to 114.9'F during the wash cycle. During the rinse cycle the temperature was 118-119'F. It went to 120'F for a couple of seconds and then back to 119'F. The unsampled dietary staff member present in the dish room stated, It's an old machine. During an interview with the DM, at 10:03 AM. She stated that the temperature is not reaching 120'F. She has called the contracted maintenance company for the dish machine and ordered a heat booster for the machine. It will be here later today, but the electrician cannot come and install it until 09/23/2021. She was asked to test the sanitizer level. The test strip was a light blue indicating less than the required 50 ppm. The DM stated that they have to prime the machine when the sanitizer level goes down. Employee C was asked how many trays have been run through the machine and she stated Oh, a lot! She stated she tested the sanitizer level earlier this morning and it was very light, like this test strip. She stated she primed the machine and re-tested the sanitizer level and it just stayed the same. She stated the color on the test strip did not get any darker. The DM then went to the primer pump on the machine and flipped the switch. She stated the sanitizer level needed to be primed. The sanitizer level was then checked, and the test strip indicated 50-75 ppm. The DM could not give an exact number of loads washed before the machine needed to be primed again. She indicated she was not aware that the sanitize level was below 50 ppm. She stated the staff should have been checking the machine more often to make sure the sanitizer level remained at or above 50 ppm. On 9/16/21 at 3:50 PM the DM was interviewed. She stated that the contracted maintenance company for the dish machine representative that came to the facility today was not same one that came on 09/14/2021. She stated he is the representative that usually comes out to work on the machine and he knows what he is doing, however, he was not able to get the wash and rinse cycle temperature up to 120'F consistently . He told her he did not know why it was not holding temp. He did fix the chemical sanitizer so that the staff do not have to keep priming the pump. She stated she did not know how long the machine was malfunctioning. She wanted the representative to install an internal thermometer inside the machine, but he could not do that until next week. Review of the manufacturer's specifications for the dish machine Model 5AG-S by ADS High Capacity revealed it read: Water temperature 120 degrees Fahrenheit minimum (Copy obtained). Review of the facility policy and procedure for Machine Washing revealed it read: Make sure the machine is functioning properly. A malfunctioning or improperly maintained machine that fails to clean tableware adequately can increase the risk of cross-contamination the next time it comes into contact with food or beverages. 1 Check the gauges and compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the data plate. Low-temperature, or chemical sanitizing machines also show minimum rinse and wash temperatures - typically 120'F for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 4 of 5 Printed: 05/28/2026 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 105816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lilac at Bayview, The 161a Marine Street Saint Augustine, FL 32084 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 0908 Level of Harm - Minimal harm or potential for actual harm both on the data plate. Chemical sanitizing machines also indicate a minimum active concentration of sanitizer on the data plate. LOW TEMPERATURE DISHWASHER *Wash temperature must be 120 -140 degrees. ** Rinse temperature must be 120-140 degrees. Sanitizer must be checked at end of rinse cycle. **CHLORINE must register 50-100 ppm. Check strip against test strip guide. **STOP washing dishes if temps are less than 120 or above 150 or chlorine is less than 50 (Copy obtained). Residents Affected - Many . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 5 of 5