Inspection·May 18, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lying in bed, awake. Her urinary catheter collection bag was observed uncovered on the door side of her bed with clear yellow urine visible in the bag and tubing to anyone walking past her room. (Photographic evidence obtained) She also had a roommate who was able to see the contents of her catheter bag. Certified Nursing Assistant (CNA) A entered the room. He was asked if he was caring for Resident #43 today. He stated yes. He was asked if her urinary catheter collection bag should be in a privacy bag. He stated, When the resident is up in her wheelchair, we use a privacy bag. We don't use them in their rooms. On 05/17/23 at 1:20 PM, Licensed Practical Nurse (LPN) B was asked if Resident #43's urinary catheter collection bag was supposed to be placed inside of a privacy bag to protect the resident's dignity. She stated, We use privacy bags when they are up in wheelchairs and outside their rooms. She was asked if residents could have privacy bags in their rooms if they preferred to have one. She stated, Yes, if they want to. Resident #43 was asked if she preferred her urinary catheter collection bag to be contained inside of a privacy bag while she was in her room. She looked at the nurse and shook her head yes. During a medical record review for Resident #43, her diagnoses included CVA (cerebral vascular accident) and obstructive reflux uropathy. A review of Resident #43's current physician's orders revealed an order written on 03/03/23: Foley Catheter 16 French/10 cc (cubic centimeters): Diagnosis: urinary retention. 2. On 05/17/23 at 2:10 PM, Resident #52 was observed ambulating on the 100 hallway with his walker. A staff member was walking with him. His urinary catheter collection bag was observed hanging on his walker with clear yellow urine visible in the bag and tubing. He was asked if he preferred that his urine collection bag was inside of a privacy bag. He stated, Heck ya, it should be in there. Let's get it inside there! During a medical record review for Resident #52, his diagnoses included suprapubic tube related to urinary retention. A review of Resident #52's care plan revealed the following intervention: Position catheter bag and tubing away from the entrance room door. During a review of the facility's policy titled Catheter Care (revised 1/6/23), the policy read: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are used. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 3. Privacy bags will be changed out when soiled, with a catheter change, or as needed. During a review of the facility's policy titled Promoting/Maintaining Resident Dignity (revised 8/2/2022), the policy read: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 2 of 17 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 05/18/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residents' quality of life by recognizing each resident's individuality. Compliance guidelines: Residents Affected - Few 1. Staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 3 of 17 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 05/18/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility document review, the facility failed to maintain a safe and sanitary living environment for 31 of 103 current residents, as evidenced by water damage in the ceilings from leaks in the roof in four resident rooms (rooms 101, 404, 407, and 408), water damage to the carpet and ceiling tiles in the hallway outside of the rehabilitation gym, missing or damaged floor tiles in seven resident rooms (rooms 205, 403, 404, 407, 408, 410, and 411) and the shower room on the 400 hall, damage to the walls in three resident rooms (rooms [ROOM NUMBER]), a light out in one resident bathroom (room [ROOM NUMBER]), an air conditioning unit unattached from the wall in one resident room (room [ROOM NUMBER]), and a broken window screen in the shower room on the 400 hall. The findings include: During multiple tours of the facility from 05/15/2023 through 05/18/2023, physical environment concerns were identified as follows: In room [ROOM NUMBER] on 05/16/2023 at 1:58 PM, the air conditioning unit was observed to be pulled away from the wall. Water damage was observed on the ceiling in the corner of the room. (Photographic evidence obtained) The bathroom light over the sink was out in resident room [ROOM NUMBER] on 05/15/2023 at 1:10 PM and on 05/18/2023 at 11:25 AM. In room [ROOM NUMBER] on 05/17/2023 at 9:33 AM, broken floor tiles were observed. (Photographic evidence obtained) In room [ROOM NUMBER] on 05/15/2023 at 1:58 PM and again on 05/16/2023 at 1:54 PM, broken floor tiles were observed. (Photographic evidence obtained) In room [ROOM NUMBER] on 05/15/2023 at 1:55 PM and again on 05/16/23 at 10:58 AM, broken floor tiles, water damage in the ceiling, and sheet rock damage with a hole in the wall were observed. (Photographic evidence obtained) In room [ROOM NUMBER] on 5/16/2023 at 10:47 AM, on 05/17/2023 at 11:49 AM, and on 05/18/2023 at 1:17 PM, broken floor tiles and water damage on the ceiling were observed. (Photographic evidence obtained) In room [ROOM NUMBER] on 05/16/2023 at 10:39 AM, water damage was observed on the ceiling. A floor board was pulled away from the wall, and damage to the air conditioning unit was observed. There was a hole in the sheet rock and broken and cracked floor tiles were observed. (Photographic evidence obtained) In room [ROOM NUMBER] on 05/16/2023 at 10:16 AM, broken floor tiles were observed. (Photographic evidence obtained) In room [ROOM NUMBER] on 05/16/2023 at 10:21 AM, broken floor tiles, damage to the sheet rock, and a missing floor board behind the headboard of the A-bed were observed. (Photographic evidence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 4 of 17 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 05/18/2023 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 0584 obtained) Level of Harm - Minimal harm or potential for actual harm In the shower room on the 400 hall on 05/16/2023 at 10:50 AM, a broken window screen was observed. The window was held open by an aerosol spray can. (Photographic evidence obtained) The hall outside of the entrance to the rehabilitation gymnasium was observed to have water damage stains to the carpet and ceiling tiles. (Photographic evidence obtained) Residents Affected - Some A review of the Maintenance Logs revealed no entries for the rooms identified above. During an interview with the Housekeeping Supervisor on 05/17/2023 at 1:29 PM, she stated she was aware of the damaged tiles on the second floor. It was not her decision to repair the tiles, they (housekeeping) just swept up the pieces and mopped the room. They tried to keep the rooms clean. She stated she thought the facility was planning to replace the floors but she did not know when. During an interview with Certified Nursing Assistant (CNA) H on 05/18/2023 at 11:25 AM, she stated she was not aware that the light over the sink in the bathroom of resident room [ROOM NUMBER] was not working. She stated, It was working the other day. She confirmed that she had given a shower in the room earlier this week but could not say which day. She thought she may not have noticed it because the light over the shower stall still worked. She did not report the light out to the maintenance department. During an interview and tour of the facility with Maintenance Department Employee F on 05/18/2023 at 12:00 PM, he stated he was unaware of the tile crumbling in room [ROOM NUMBER]. He was shown the other rooms with tile damage and stated he could replace the tiles. He was not aware of the floor board coming away from the wall in room [ROOM NUMBER]. He said he could repair and replace it. He stated the walls behind the headboard with damage and holes in the sheet rock could be repaired and replaced. He stated, Yeah, I can do that. He was not aware of the ceilings with water damage. He explained that the reason for the ceiling damage was due to leaks in the roof. Every time it rains there are leaks. He was aware that the facility had a plan to fix the roof and had a company they wanted to contract with, but the company wanted over one million dollars to fix the roof. They haven't done it yet. He confirmed that there were no entries in the maintenance logs for the broken tiles, walls or ceiling damage. During an interview and tour of the facility with the Administrator on 05/18/2023 at 12:39 PM, he stated he was aware of the physical environmental concerns. The facility had obtained a proposal from a local building contractor to replace tiles and repair the damage to the walls in the facility. They renovated a room on the first floor last year and the first floor was their priority. They had not contracted with the local building contractor yet. He acknowledged the floor tiles were in disrepair. He was not aware of the damage to the sheet rock behind the bed in room [ROOM NUMBER]. He was not aware of the water damage on the ceilings of rooms [ROOM NUMBERS]. He stated the local building contractor would repair the tiles, walls and floor boards. The shower room damage and the damage in room [ROOM NUMBER] was observed. He stated the water damage on the ceilings was from the roof leaking. He stated the project was estimated to be 1.7 million dollars and the company they wanted to contract with wanted 50% of the cost up front before they would begin the work. The facility had not paid the 50% yet. He stated it would do no good to repair the water damage in the ceilings in the resident rooms until the whole roof could be repaired. It will just continue to damage the ceilings when it leaks. He stated the shower room on the second floor leaked to the first floor resident room which was now locked for renovation. The shower room was toured. The wall was taped up with a black plastic barrier where the wall had been cut open to expose the pipes. The shower head was leaking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 5 of 17 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 05/18/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Photographic evidence obtained) room [ROOM NUMBER] on the first floor where the water had leaked down through the wall was toured. Water damage to the wall was observed in two places. The sheet rock had been cut away to get to the pipes. The floor boards had been removed. Water damage was observed to the ceiling of the room. The administrator stated he did not want to burden his maintenance department staff with the repair of the walls and tiles. They already have so much to do. A review of the proposal from the local building contractor for repair of the walls and ceiling, dated 05/15/2023, revealed the proposal was estimated to cost the facility $22,037.00. The Administrator stated, It was really bad last year when I got here and we have made some improvements. We know we have a lot to do. (Copy obtained) No proposal for repair of the roof was provided. A review of the facility's 2023 Quality Assurance & Performance Improvement (QAPI) Plan revealed: The scope of the QAPI program encompasses all segments of care and services provided by [facility] that impact clinical care, quality of life, resident choice, and care transitions with participation from all departments. For Example: Maintenance and Engineering. We provide comprehensive building safety, repairs, and inspections to ensure all aspects of safety are enforced, assuring the safety and well-being for each resident, visitor, and staff who enters the building. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 6 of 17 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 05/18/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview with Resident #28 on 05/16/2023 at 10:26 AM, she stated she was in severe pain all the time. She stated she received medication, however, it did not help. She stated she informed the nurse that the medication did not help. Certified Nursing Assistant (CNA) A was seated next to the resident. He stated the facility did not offer non-pharmacological approaches/interventions to help the resident with her pain. They put her in bed and let her lie on her side. Sometimes that helped. The resident then stated it did not help to lie down. She confirmed that the reason she yelled out was due to the extreme pain she felt. She then stated that her breast was hurting and put her hand up over her left breast. She declined the offer to be put back in bed. A review of the medical record for Resident #28 revealed the face page indicated the resident was initially admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side; major depressive disorder, recurrent moderate, chronic embolism and thrombosis of other specified veins, hyperlipidemia, hypertension, gastro-esophageal reflux disease (GERD) without esophagitis, and Type II diabetes with other circulatory complications. (Copy obtained) A review of the resident's active physician's orders revealed the following: Acetaminophen oral tablet. Give 1000 milligrams (mg) by mouth every 8 hours as needed (PRN) for pain. Start date: 01/14/2023. Lidoderm External Patch (Lidocaine). Apply to lower back 4% patch topically one time a day for back pain and remove per schedule. Start date: 01/30/2023. (Copy obtained) A review of the Medication Administration Record (MAR) for the month of April 2023, revealed Resident #28 received Acetaminophen 1000 mg as needed for pain seven times. A review of the MAR from May 1, 2023, through May 15, 2023, revealed that the resident did not receive Acetaminophen 1000 mg during that time. (Photographic evidence obtained) A review of the Quarterly MDS assessment, dated 04/21/2023, revealed that Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points, indicating moderately impaired cognition. Her hearing, speech and vision were documented as adequate. She understood others and was understood. She had no hallucinations or delusions documented. She did have behaviors directed toward others such as verbal/vocal symptoms like screaming and disruptive sounds, which occurred during 4 to 6 days of the assessment period. The resident did not walk during the assessment period. Extensive assistance of one person was required for activities of daily living (ADLs). She required supervision for eating with set-up help only. She was totally dependent on one staff member for bathing. She received scheduled and PRN pain medications, but no non-medication interventions for pain. The resident reported having occasional mild pain during the assessment period. She had no pressure ulcers and received seven days of antianxiety, antidepressant, and anticoagulant medications daily, and antibiotic during three days of the assessment period. (Copy obtained) A review of the resident's care plan, dated 01/25/2023, and revised on 04/24/2023, revealed the following for the following focus area: Potential For Pain. The goal read [Resident #28] will have no interruption in normal activities related to pain through next review. The interventions included: Notify MD (physician) of problems, changes, concerns, chart accordingly. For the focus area: [Resident #28] Is At Risk For Behaviors Such As Paranoia and Anxiety. Occasionally Yells Out During the Day, dated 05/03/2023, with a target date of 07/23/2023. The goal read: Resident will show a therapeutic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 7 of 17 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 05/18/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few response to medication and decreased behaviors through next review date. The interventions included: Document outcomes and notify MD as needed. (Copy obtained) A review of the Progress Note dated 04/18/2023, revealed: History of Present Illness: Past psychiatric history of depression and anxiety. Prior to last visit, patient had behaviors like yelling out and also had some paranoia. Alprazolam (Xanax - a benzodiazapine medication used to treat anxiety) was helpful. No depressive symptoms were noted. Sleep and appetite were fair. Alprazolam was increased. During last visit no behaviors were observed. Patient is alert, oriented x 3 today. She reports pain in back. The note was authored by the psychiatric mental health nurse practitioner. The note did not indicate that the nurse practitioner notified the attending physician of back pain as reported by the resident. (Copy obtained) During an interview with Resident #28's attending physician on 05/16/2023 at 2:15 PM, he was asked if Resident #28 received only PRN pain medication. He confirmed that her oral pain medication was prescribed as PRN (as needed) only. He stated she received a scheduled pain patch daily. When informed that the resident was describing her pain as severe and that she was crying out due to the intensity of her pain, he stated, It's the first I've heard of it. He was informed that the resident stated her pain medication did not work. He confirmed that the only pain medication she received was PRN Acetaminophen and a topical patch. He stated he would look at it today. He stated the resident may not ask for the PRN pain medication if she did not think it worked. During an interview with Resident #28's Unit Manager on 05/17/23 at 10:20 AM, she stated Resident #28's behavior of yelling out was fairly recent. She had not always had that behavior. The facility staff offered her non-pharmacological alternatives such as redirecting her, and taking her outside on the second level terrace. This seemed to help calm her down. The assigned nurse would rub her back. Sometimes she wanted attention and would call out to the staff member when they left her room. When they asked her if she needed anything, she would not say what she wanted. The Unie Manager had not heard the resident complain of back pain. She confirmed the resident received PRN oral pain medication and a pain patch. She stated the pain the resident was experiencing could be increasing her behavior of yelling out. During an interview with Registered Nurse (RN) D (Resident #28's assigned nurse) on 05/18/2023 at 10:05 AM, she stated the nurses were to notify the physician if they observed new behaviors or changes in a resident's condition. They were to document notification of the resident's physician in the progress notes. She stated sometimes they would document it in the 24-hour report. She had noticed that Resident #28 was yelling out more than she used to. RN D confirmed that she had not notified the physician of this. A review of the 24-hour report from 04/28/2023 through 05/18/2023, revealed one entry for Resident #28 on 05/15/2023. The form read: Excessive calling out. The form did not indicate that the physician had been notified. The 05/16/2023 form read: New wound to sacrum. New orders for pain meds. The form dated 04/28/2023 read: Transfer from first floor. The forms did not indicate the physician had been notified of the new/increased behavior. (Copies obtained) During a second interview with Resident #28 on 05/17/2023 at 10:12 AM, she was observed sitting quietly in the hallway outside of her room. She stated she had back pain and it felt like there were boards in her back. She was informed that her pain medication had been changed to a daily dose. An interview was conducted with the Director of Nursing (DON) on 05/18/2023 at 1:12 PM. When she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 8 of 17 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 05/18/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm was informed of the lack of notification to the attending physician about Resident #28's yelling and complaints of pain, she stated, If it's not documented, it's not done. She stated the resident's physician was aware of her yelling behavior. She used to live on the first floor and he had been Resident #28's physician the entire time she had been employed by the facility. Her yelling behavior was not new. She was not aware of the resident complaining of back pain. Residents Affected - Few A review of the facility policy and procedure for Pain Management, dated 11/2020, and revised on 7/25/2022, revealed: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain: i. Negative vocalizations (e.g., groaning, crying, whimpering, or screaming). Pain Management and Treatment. 7c. Consider administering medication around the clock instead of PRN (pro re nata/on demand). 7i. Facility staff will notify the practitioner if the resident's pain is not controlled by the current treatment regimen. (Copy obtained) Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to develop and/or implement a comprehensive person-centered care plan for two (Residents #43 and #28) from a total sample of 31 residents, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Each resident must have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and to address the resident's medical, physical, mental and psychosocial needs. The facility failed to develop a person-centered care plan focus area for Resident #43 regarding her urinary catheter. Resident #43 was one of three residents identified with a urinary catheter. The facility failed to implement care plan interventions for Res #28 regarding her pain. The findings include: 1. On 5/15/23 at 12:50 PM, Resident #43 was observed with a urinary catheter. During a medical record review for Resident #43, it was revealed that her quarterly comprehensive Minimum Data Set (MDS) assessment, dated 4/27/23, included documentation in Section H: indwelling catheter. A review of her active physician's orders revealed an order dated 3/3/23: Foley Catheter 16french/10cc (cubic centimeters): Diagnosis: urinary retention. A review of her person-centered comprehensive care plan revealed no focus area related to her use of a urinary catheter. On 5/17/23 at 2:42 PM, during an interview with Licensed Practical Nurse (LPN) C/MDS Nurse, she was asked if she initiated the residents' comprehensive care plans. She stated yes. She was asked if Resident #43 had a care plan for her urinary catheter which was ordered on 3/2/23. LPN C reviewed the medical record and stated, I'm not seeing one in her chart. She was asked if a comprehensive care plan focusing on the resident's urinary catheter would be an expectation. She stated yes. She was asked when this care plan should have been initiated. She stated, Within a day of her getting the catheter. A review of the facility's policy titled Comprehensive Care Plans (revised 1/6/23), revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 9 of 17 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 05/18/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. Residents Affected - Few Policy Explanation and Compliance Guidelines: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the residents comprehensive assessment. The objectives will be utilized to monitor the resident's progress. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. (Copy obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 10 of 17 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 05/18/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #27) of seven residents who relied on supplemental oxygen, from a total of 31 residents sampled, was administered oxygen, consistent with professional standards of practice and the comprehensive person-centered care plan. The findings include: On 05/15/23 at 10:55 AM, Resident #27 was observed lying in bed. She had no oxygen nasal cannula in place, however, her bedside oxygen concentrator was running and the flow rate was set at 3 LPM (liters per minute). The resident was asked if she wore her oxygen on a regular basis. She stated, When I need it. She was asked if she adjusted the oxygen flow rate on her oxygen concentrator. She stated, No, I wouldn't do that. The nurse does that. I can't even reach it from here. A medical record review for Resident #27 revealed she was admitted to the facility on [DATE]. Further review revealed an order written on 05/15/23, which read: 02 @ 2 LPM NC continuous (oxygen at 2 liters per minute via nasal cannula, continuously). A review of the Comprehensive Minimum Data Set (MDS) assessment, dated 04/12/23, revealed the resident was not coded as using oxygen in the facility at the time. She was recorded with a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points on that date, indicating intact cognition. On 05/15/23 at 3:00 PM, Resident #27 was observed lying in bed, awake, without her oxygen nasal cannula in place. Her bedside oxygen concentrator was running and the flow rate was set at 3 LPM. The resident was asked why her oxygen cannula was not on her face/nose. She stated, I don't know. (Photographic evidence of flow rate setting was obtained) On 05/16/23 at 9:48 AM, Resident #27 was observed lying in bed, awake. Her oxygen nasal cannula was in place. Her bedside oxygen concentrator was running and the flow rate was set at 3 LPM. (Photographic evidence obtained) On 05/16/23 at 2:15 PM, Resident #27 was observed lying in bed, awake. Her nasal cannula was in place. Her bedside oxygen concentrator was running and the flow rate was set at 3 LPM. (Photographic evidence obtained) On 05/17/23 at 9:40 AM, Resident #27 was observed in her room. Her nasal cannula was not in place. Her oxygen concentrator was running and the flow rate was set at 3 LPM. (Photographic evidence obtained) Resident #27 was asked why her nasal cannula wasn't in place on her face. She stated, I don't know. Sometimes it's on, sometimes it isn't. Licensed Practical Nurse (LPN) D entered the room at this time. She was asked if she was caring for Resident #27 today. She stated yes. She was asked what the resident's oxygen flow rate should be set at. She stated, 3 liters, I think. Or 2 liters. She was asked what the resident's flow rate was currently set at. LPN D looked at the setting and said, It's at 3 liters. She was asked when she checked the oxygen flow rates for her residents. She stated, I check at start of shift and whenever I come in for medications or to answer the call light, and at end of shift. A review of the facility's policy for Oxygen Administration (revised 5/4/22), revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 11 of 17 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 05/18/2023 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 0695 Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: Residents Affected - Few 1. Oxygen is administered under orders of a physician except in the case of an emergency. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 12 of 17 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 05/18/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. Medication administration observations were conducted with four nurses on all three shifts. There were 25 opportunities for error with three medication errors involving Residents #80 and #27 for a medication error rate of 12%. Residents Affected - Few The findings include: On 05/17/23 at 5:30 AM, Registered Nurse (RN) E was observed preparing and administering medications to Resident #80. The medications being prepared included an order for Digoxin 125 mcg (micrograms), one tablet by mouth daily (hold for HR <60 (heart rate less than 60). The nurse checked the resident's vital signs with an electronic device on his right upper arm. The nurse stated the vital signs showed a blood pressure of 106/66 and a pulse of 69. The nurse did not check the resident's apical pulse for one minute prior to administering the Digoxin. On 05/17/23 at 5:55 AM, in an interview with RN E, he was asked how he was trained to monitor vital signs when administrating Digoxin. He stated, I check the blood pressure and pulse. He was asked if he checked the resident's pulse apically or by using an electronic monitoring device. He stated, I use the machine. It is accurate. I know sometimes in the hospitals they require to check the pulse apically, but we use the machine. It's calibrated every day so it's accurate. On 05/17/23 at 8:50 AM, in an interview with the Assistant Director of Nursing (ADON), he was asked what the expectation was for nurses taking a resident's vital signs prior to the administration of Digoxin. He stated, Before it's administered, check their vitals. The policy is an order for Digoxin would have parameters, depending on what the doctor wants for parameters. He was asked what the expectation for vital signs to be taken prior to Digoxin being administered to a resident were. He stated, An apical pulse should be taken. On 05/17/23 at 10:10 AM, Licensed Practical Nurse (LPN) D was observed preparing and administering medications to Resident #27. These medications included: Metoprolol Tartrate 25 mg (milligrams), give 1.5 tablets by mouth daily for hypertension. Fludrocortisone Acetate 0.1 mg, one tablet by mouth daily for hypotension (hold for SBP >140 (systolic blood pressure greater than 140) LPN D was observed to pouring only one half tablet of Metoprolol 25 mg (12.5mg) into the medication cup for Resident #27. Just before entering the room, she was asked if this was the medication, she intended to administer to Resident #27. She stated yes. She was advised at that time to review the order again. LPN D read the order out loud and stated she felt the order of 1.5 tablets meant to administer one half of one tablet. She was advised to read the order out loud again from the original order. She read the original order which instructed staff to provide Metoprolol 25 mg tablet, administer 1.5 tablets by mouth daily for hypertension. LPN D was asked what the blood pressure for Resident #27 was prior to administering her medications. She stated, I took it. It was 147/77. She was asked to read the order for Fludrocortisone Acetate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 13 of 17 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 05/18/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 0.1 mg out loud. She read the order and stated, Oh, I messed up. I shouldn't have given that because her systolic blood pressure was above 140. A review of the facility's policy titled Medication Administration (revised 5/3/22) revealed: Medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physicians' orders. 10. Review MAR (medication administration record) to identify medication to be administered. 11. a. Refer to drug reference material if unfamiliar with the medication. 14. Administer medication as ordered in accordance with manufacturer specifications. According to The [NAME] Drug Guide: https://www.drugguide.com/ddo/view/[NAME]-Drug-Guide/51218/all/digoxin (accessed on 5/17/23 at 10:00 AM): Monitor apical pulse for one full minute before administering. Withhold dose and notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant. Notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. The apical pulse in monitored because beginning of Digoxin toxicity could be indicated by an apical pulse of less than 60. An apical pulse also allows for monitoring of skipped beats and abnormal rhythm changes. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 14 of 17 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 05/18/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observations, record review and interviews, the facility failed provide sufficient kitchen staff with the appropriate competencies and skills sets to carry out the functions of food and nutrition service. Failure to ensure that dietary staff were trained and knowledgeable about the proper procedures for food safety and sanitation had the potential to negatively impact all residents who received meals from the kitchen. The findings include: A kitchen tour was conducted on 05/17/23 at 11:00 a.m. There were two cooks in the kitchen at the time of the tour. [NAME] I was asked to explain the food thermometer calibration process. She replied, A glass of ice water and the thermometer should read above 80°F. When asked, what should the thermometer read to ensure the thermometer is working accurately. She replied, above 80°F. When asked, what training she had been provided in the kitchen or food safety and sanitation. [NAME] I replied, I've been employed with the facility only seven months but received kitchen training from my previous job. [NAME] J was also asked to explain the food thermometer calibration process. He replied, It should be above 80°F. During the interview with both cooks, Dietary Manager L stated, 32. Afterwards, [NAME] J replied, It should be above 32. At this time, [NAME] I attempted to calibrate a thermometer, but the thermometer would not register below 38°F after being held in the ice bath for several minutes. More ice was added to the cup. The second thermometer used would not register below 33°F after several minutes in the ice bath. The third thermometer used calibrated to 32°F. In an interview conducted on 05/18/23 at 12:55 p.m. with [NAME] I, she reported the Dietary Manager and Cooks provided initial training for one week on the tray line and meal ticket process to new Cooks and Dietary Aides. In an interview conducted on 05/18/23 at 12:55 p.m. with Dietary Aide K, she confirmed she was trained by the Dietary Manager and Chef but had only received training on hand washing and the tray line process since her employment with the facility for one month. In an interview conducted on 05/18/23 at 1:25 p.m. with Certified Dietary Manager (CDM) M, he confirmed staff training was provided monthly and topics included cleaning and sanitizing, tray cart accuracy, diets, tray line, and customer service. A review of Dietary Department training since the facility's previous recertification date of 9/16/2021, revealed four trainings: Renal Diet, dated 1/24/2023, Phone Answering and Kitchen Door, dated 2/20/2023, Handwashing and Ware, dated 3/21/2023, and Thermometers dated 5/17/2023. The CDM reported, There was no training prior to CDM and Dietary Manager. A review of the facility's policy titled Sanitation/Infection Control, Sanitation F340 (Undated), revealed: 1. Effective sanitary practices include, but are not limited to, the following: a. The Dietary Manager is responsible for supervising and training all personnel in proper sanitation procedures for storing, preparing, and serving foods. Policy: To ensure accuracy of food temperatures. Procedure: Thermometer Calibration. HCCP based food safety programs require accurate record keeping to be successful. Temperature is often the parameter of interest when monitoring a critical control point (CCP). (Copy Obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 15 of 17 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 05/18/2023 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 0802 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 16 of 17 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 05/18/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, and medical record review, the facility failed to ensure standard precautions were followed to prevent spread of infections for one (Resident #43) of three residents who relied on a urinary catheter collection bag, from a total sample of 31 residents. The resident's urinary catheter collection bag was allowed to rest directly on the floor. Residents Affected - Few The findings include: On 05/16/23 at 1:35 PM, Resident #43 was observed from the hallway. Her door was open, and she was lying in bed on her right side. Her urinary catheter collection bag was observed uncovered on the door side of her bed and was observed touching floor. (Photographic evidence obtained) After all care had been provided by staff for Resident #43 on 5/16/23 at 2:00 PM, her urinary catheter collection bag was observed on the window side of her bed, uncovered, with clear yellow urine observed in the collection bag. The bag was resting on the floor. (Photographic evidence obtained) On 05/17/23 at 9:35AM, in an interview with Certified Nursing Assistant (CNA) A, he was asked if he was caring for Resident #43 today. He stated yes. He was asked if the urinary catheter collection bag should be touching the floor. He stated, No, never. It shouldn't touch the floor. It should be up off the floor. He was asked why it shouldn't touch the floor. He stated, Germs, we don't want germs on the Foley bag. On 05/17/23 at 1:20 PM, Resident #43 was observed lying in bed, awake. Her urinary catheter collection bag was observed on the door side of her bed with clear yellow urine visible in the collection bag and tubing. The bag was touching the floor. (Photographic evidence obtained) During a medical record review for Resident #43, it was revealed that she had a current order, dated 03/03/23, which read: Foley catheter 16 French/10 cc (cubic centimeters): Diagnosis: urinary retention. Further review revealed two more current orders, dated 03/02/23, which read: Foley catheter care every shift; and frequent rounding to ensure safety and comfort. A review of the CDC (Centers for Disease Control and Prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (accessed at https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html on 05/17/23 at 2:20 PM) read: III. Proper Techniques for Urinary Catheter Maintenance 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105816 If continuation sheet Page 17 of 17