Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure residents with newly evident or possible serious
mental disorders, intellectual disability, or related conditions were reviewed for level II pre-admission
screening and resident review (PASRR) for one (Resident #87) of two residents reviewed for PASRR.
The findings include:
A record review for Resident #87 was conducted on 04/08/25 at 6:30AM and read, PASRR signed by RN
(registered nurse) on 7/03/24 from hospital with depressive d/o (disorder). No Level II needed.
A review of the resident's medical diagnoses for the facility on 7/10/24 included anxiety d/o (disorder),
psychosis and brief psychotic d/o.
A review of the resident's admission summary, dated [DATE], read, Resident arrived via stretcher from
[acute care hospital name] via Stat @ 1515 (3;15 PM). She is alert and oriented. Spanish speaking but
understands and speaks limited English. DX CVA (Diagnosis cerebrovascular accident) She is a Full Code.
POA (Power of Attorney) contacted for verbal consents via phone. She is a 2-person assist with right side
and bilateral lower extremity weakness. HX (History) diabetes, HIV (human immunodeficiency virus), GERD
(gastroesophageal reflux disease), dementia, HTN (hypertension - high blood pressure), HDL
(hyperlipidemia), depression. Last BM (bowel movement) 7/8/24. She is on a Cardiac Puree diet/thin liquids
(diet). Take pills whole. Bruising to bilateral (both) arms, abdomen. Lungs clear, abdomen soft with bowel
sounds times 4 quad (quadrants). Denies pain/discomfort. Resident resting in bed at present.
A Psychiatry Referral Order read, Chief Complaint: Depression, anxiety, dementia and psychosis. Reason
for Today's Evaluation: I was consulted for psychiatric evaluation and treatment of depressed mood and
anxiety. History of Present Illness: This is an [AGE] year-old patient with past psychiatric history of
depression, anxiety, dementia and psychosis. Patient is a new admit to this facility requiring evaluation for
underlying psychiatric conditions and treatment. Facility requested a consult. I was consulted for psychiatric
evaluation and treatment of depressed mood and anxiety.
An interview was conducted with the Director of Nursing (DON) on 4/09/25 at 9:35 AM related to PASRR.
The DON stated the facility did not have any documentation that indicated Resident #87's Level I PASRR
had been revised to show a diagnosis of anxiety disorder or psychosis and to initiate a Level II PASRR
screening.
A review of the facility's policy and procedure titled Resident Assessment-Coordination with PASRR
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
105816
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
04/10/2025
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
(Preadmission Screening and Resident Review) Program (dated 11/03/20, revised 9/19/02) revealed: This
facility coordinates assessments with the preadmission screening and resident review (PASRR) program
under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition
receive care and services in the most integrated setting appropriate to their needs. 9. Any resident who
exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition, will
be referred promptly to the state mental health or intellectual disability authority for a level II resident review.
a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a
mental disorder (where dementia is not the primary diagnosis).
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 2 of 11
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
04/10/2025
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to stop enteral feeding as ordered by
the physician for one (Resident #305) of two residents reviewed for gastrostomy tube enteral feedings.
Residents Affected - Few
The findings include:
A review of Resident #305's medical record revealed an admission date of 4/1/2025 with diagnoses
including severe protein-calorie malnutrition, dysphagia (difficulty swallowing) and gastrostomy status
(G-tube - feeding tube passed into a resident's stomach through the abdominal wall).
A review of Resident #305's physician's orders, dated 4/7/2025, read, Enteral feed order every shift for
nutritional support administer Jevity 1.5 40 ml/hr (milliliters/hour) via G-tube continuously with (200 ml)
autoflush every hour for (4) hours (1200). 20 hours a day. Start infusion daily at (1400 p) and stop infusion
at (10:00 a). Ensure to record amount infused to record amount infused per pump reading once a shift.
During an observation on 4/8/2025 at 12:10 PM, Jevity 1.5 Cal/Fiber Oral Liquid (Nutritional Supplement)
was observed infusing at 40 ml via G-tube.
During an interview with Registered Nurse (RN) A, she stated, The feeding was supposed to be turned off
at 10:00 AM and restarted at 2:00 PM. I'm always late giving my meds (medications) and I didn't pay
attention to the time. The feeding should have been turned off at 10:00 AM.
During an interview on 4/8/2025 at 12:40 PM with Licensed Practical Nurse (LPN) B/Nurse Manager, she
stated, Physician's orders must be followed, and the tube feeding should have been turned off at 10:00 AM,
as ordered.
During an interview with the Director of Nursing on 4/8/2025 at 12:58 PM, she stated, Physician's orders
must be followed and the Jevity should have been turned off at 10:00 AM as ordered.
A policy and procedure for following physicians' orders was requested; however, no policy was received
during the survey.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 3 of 11
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
04/10/2025
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure nutritional interventions were
implemented as ordered by the physician for two (Residents #94 and #89) of nine residents reviewed for
nutrition.
Residents Affected - Few
The findings include:
1. A review of Resident #94's care plan, revised 3/9/2025, revealed the resident was at nutritional risk
related to therapeutic mechanically altered diet and autoimmune gastritis weight loss in 90 days.
A review of Resident #94's weight record revealed that on 3/5/2025, Resident #94 weighed 170 pounds,
and on 4/1/2025, he weighed 165.5 pounds, which was a - 2.65 % weight loss. Resident #94's weight
record showed that on 11/6/2024, he weighed 204 pounds, and on 4/1/2025, he weighed 165.5 pounds,
which was a - 18.87 % weight loss.
A review of Resident #94's physician's orders revealed that he had a physician's order, dated 3/20/2025,
which read, (Name of supplement) one time a day 120 ml (milliliters) one time a day PO (by mouth), record
amount consumed.
A review of Resident #94's medication administration and treatment administration records, dated April
2025, failed to reveal documentation that showed the amount of nutritional supplement consumed by
Resident #94 had been recorded as ordered by the physician.
Further review of Resident #94's physician's orders showed the resident had a physician's order, dated
3/5/2025, which read, ST (speech therapy) consult r/t (related to) weight management hx: (history):
Dysphagia.
A review of the resident's medical record failed to show documentation that Resident #94 had been referred
to speech therapy for evaluation related to weight management as ordered by the physician.
During an interview on 4/9/2025 at 10:30 AM, the Director of Rehabilitation stated Resident #94 had not
been referred to speech therapy for an evaluation related to weight management as ordered by the
physician. She explained that nursing staff would complete referrals to therapy after the physician wrote an
order for therapy.
During an interview on 4/9/2025 at 10:37 AM, Licensed Practical Nurse (LPN) C confirmed that Resident
#94 had a physician's order to document the amount of nutritional supplement consumed by the resident.
LPN C confirmed that the physician's order had not been followed, and the amount of the nutritional
supplement consumed by Resident #94 had not been recorded as ordered by the physician. LPN C stated
she was not aware of the physician's order for Resident #94 to be referred to speech therapy related to
weight management. She stated there was no system to flag new orders by the physician, and the only way
to know new orders would be to check the orders or to have the new order passed on by another nurse.
During an interview on 4/10/2025 at 8:54 AM, the Registered Dietician (RD) stated recording the amount of
a supplement consumed would assist the provider to know whether a nutritional intervention was beneficial
for a resident.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 4 of 11
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
04/10/2025
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
2. A review of Resident #89's care plan, revised 3/9/2025, revealed that the resident was at risk for altered
nutrition related to use of psychotropic agents and significant weight loss in 30 days.
A review of Resident #89's weight records showed on 3/6/2025, Resident #89 weighed 128.6 pounds, and
4/1/2025, Resident #89 weighed 127.5 pounds, which was a - 0.86 % weight loss. Resident #89's weight
records showed that on 12/24/2024, Resident #89 weighed 136.8 pounds, and on 4/1/2025, Resident #89
weighed 127.5 pounds, which was a - 6.80 % weight loss.
A review of Resident #89's physician's orders showed that the resident had a physician's order, dated
3/17/2025, that read (Name of Supplement) one time a day 120 ml (milliliters) one time a day PO (by
mouth), record amount consumed.
A review of Resident #89's medication administration and treatment administration records, date April 2025,
failed to reveal documentation that showed the amount of nutritional supplement consumed by Resident
#89 had been recorded as ordered by the physician.
During an interview on 4/9/2025 at 10:46 AM, LPN C confirmed that Resident #89 had a physician's order
to document the amount of nutritional supplement consumed by the resident. She confirmed that the
physician's order had not been followed, and the amount of the nutritional supplement consumed by
Resident #89 had not been recorded as ordered by the physician.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 5 of 11
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
04/10/2025
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
Based on observation, interview, and record review, the facility failed to ensure that the medication error
rate was not 5% or greater for two (Residents #254 and #305) of seven residents observed during
medication administration, resulting in a medication error rate of 6.45%.
Residents Affected - Few
The findings include:
1. During medication administration observation for Resident #254 on 4/8/2025 beginning at 11:00 AM,
Registered Nurse (RN) A verified orders, prepared and initiated Cefepime HCL (hydrochloride - antibiotic)
solution 50 ml (milliliters) intravenously (IV), and initiated instillation via pump over 1 hour. Medication was
due at 9:00 AM and was administered 2 hours late.
A review of Resident #254's physician's orders, dated 4/8/2025, read, Cefepime HCL Solution 1 GM/50ML
(grams per milliliters), Use 1 gram intravenously every 12 hours for UTI (urinary tract infection)for 7 Days.
A review of the resident's April 2025 Medication Administration Record (MAR) revealed, Cefepime HCL
Solution 1 GM/50ML, Use 1 gram intravenously every 12 hours for UTI for 7 days start date 4/8/2025 at
0900.
During an interview on 4/8/2025 at 11:59 AM with RN A , she stated, I am always late with my medications,
and this medication is due once a day. It was due at 9:00 AM.
2. During medication administration observation for Resident #305 on 4/8/2025 at 12:10 PM, RN A verified
orders, prepared and initiated Daptomycin (antibiotic) Intravenous Solution Reconstituted (Daptomycin
INFUSE 100 ML NS (600 MG)(milligrams) IV OVER 30 MIN AT 200 ML/HR, administered 4 hours late.
A review of Resident #305's physician's orders, dated 4/3/2025, revealed, Daptomycin Intravenous Solution
Reconstituted (Daptomycin INFUSE 100ML NS (600 MG) IV OVER 30 MIN AT 200ML/HR EVERY 24
HOURS FOR BACTEREMIA UNTIL 4/22/2025 at 23:59.
A review of Resident #305's April 2025 MAR documented 4/3/2025, Daptomycin Intravenous Solution
Reconstituted (Daptomycin INFUSE 100ML NS (600 MG) IV OVER 30 MIN AT 200ML/HR EVERY 24
HOURS FOR BACTEREMIA UNTIL 4/22/2025 at 23:59 with administration documented scheduled at
08:00 daily.
During an interview on 4/8/2025 at 12:30 PM with RN A, she stated, [Resident #305's] Daptomycin is to be
administered every 24 hours. It is scheduled at 8:00 AM, but I am always late giving out my medications.
During an interview on 4/8/2925 at 12:40 PM with Licensed Practical Nurse (LPN) B/Nurse Manager, she
stated all medications should be given no earlier than 1 hour before and no later than 1 hour after the
scheduled time.
During an interview on 4/8/2025 at 12:58 PM with the Director of Nursing (DON), she stated, Medications
are to be administered anytime 1 hour before or 1 hour after they are scheduled. If they are not
administered within that hour before or after, I consider that they are administered late.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 6 of 11
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
04/10/2025
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
During an interview on 4/9/2025 at 9:49 AM with the Assistant Director of Nursing (ADON), the ADON
stated, The timeframe for medication to be administered on time is 1 hour before and up to 1 hour after they
are scheduled. If the medications can not be administered on time, the doctor is to be called and informed.
A review of the facility's policy and procedure titled Medication Administration (dated 1/30/2025), revealed:
Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this
state, as ordered by the physician and in accordance with professional standards of practice, in a manner
to prevent contamination or infection . 11. b. Administer within 60 minutes prior to or after scheduled time
unless otherwise ordered by physician .
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 7 of 11
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
04/10/2025
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, interview, and record review, the facility failed to ensure that all drugs and
biologicals used in the facility were properly stored in accordance with professional standards of practice.
Unsecured medications were found on two of four hallways and affected three residents (Residents #55,
#52, and #73).
The findings include:
1. During an observation on 4/7/2025 at 10:49 AM of Resident #55's room, two bottles of medication were
observed sitting at bedside unsecured. The bottles were labeled: Prevagen and Cerebral. (Photographic
evidence obtained)
During an observation on 4/8/2025 at 8:13 AM of Resident #55's room, two bottles of medication were
observed sitting at bedside unsecured. The bottles were labeled: Prevagen and Cerebral. (Photographic
evidence obtained)
During an interview on 4/8/2025 at 8:13 AM, the resident stated he took Prevagen and Cerebral pills daily
and had done so for months. He stated he had the pills in his room for months.
2. During an observation on 4/7/2025 at 11:19 AM of Resident #52's room, a medication cup with 7
unidentified pills was observed sitting on Resident #52's bedside table unsecured.
During an interview on 4/7/2025 at 11:19 AM, Resident #52 stated, Those are pills from this morning. I will
not take them until after I eat and I did not want to eat this morning. I took my blood pressure pill only.
(Photographic evidence obtained)
During an interview on 4/8/2025 at 12:40 PM with Licensed Practical Nurse (LPN) D, she stated, No
medications are allowed in the room unsecured. I did not leave any medications in there. She (Resident
#52) has refused her medications for the last two days and I threw them away this morning.
During an interview on 4/8/2025 at 12:48 PM with LPN B/Unit Manager, she stated, No, medications even
over the counter are not allowed in the room unless they (the residents) have been screened for
self-administration, and they have a lock box then, so that they can secure their medications.
During an interview on 4/8/2025 at 12:58 PM with the Director of Nursing (DON), she stated, No over the
counter medications or prescription medications can be left at the bedside. The nurse should be watching
the residents take their scheduled medications before leaving the room.
3. During an observation on 4/8/2025 at 11:25 AM of Resident #73's room, a medication cup with an
unidentifiable pink pill was sitting on the resident's bedside table unsecured.
During an interview on 4/8/2025 at 11:26 AM, Resident #73 stated, That's my medication. They leave that
there until I get some food to take it with. When asked if they left the medications there all the time, the
resident replied, yes.
During an interview on 4/8/2025 at 11:33 AM, LPN C confirmed there was medication in the cup
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 8 of 11
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
04/10/2025
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 0761
sitting on Resident #73's bedside table and stated, No, medication should not be left at bedside.
Level of Harm - Minimal harm
or potential for actual harm
A review of Resident #73's Electronic Medical Record (EMR) revealed that the resident entered the facility
on 12/24/24 with diagnoses including Interstitial Pulmonary Disease, Kidney Disease, Proximal Atrial
Fibrillation, Essential (primary) Hypertension, and Rheumatoid Arthritis.
Residents Affected - Few
Review of Resident #73's EMR revealed that the resident had no assessment for self-administration of
medication.
During an interview on 4/8/2025 at 1:30 PM, the Director of Nursing stated, There are no residents here
that are supposed to have meds (medications) at bedside.
A review of the facility's policy and procedure titled Medication Storage (dated 1/30/2025), revealed: It is the
policy of this facility to ensure that all medications housed on our premises will be stored in the pharmacy
and/or medication rooms according to the manufacturers' recommendations and sufficient to ensure proper
sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. General guidelines:
a. All drugs and biologicals will be stored in locked compartments (i.e. medications carts, cabinets, drawers,
refrigerators, medication rooms) under proper temperature controls . c. During a medication pass,
medications must be under the direct observation of the person administering medications or locked in the
medication storage area/cart.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 9 of 11
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
04/10/2025
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain an infection prevention and control
program to prevent the possible development and transmission of communicable diseases and infections.
Specifically, the facility failed to ensure the staff followed Enhanced Barrier Precautions (EBP) for two
(Residents #254 and #305) of seven residents reviewed for infection with use of antibiotics.
Residents Affected - Few
The findings include:
1. A review of Resident #254's medical record revealed an admission date of 3/28/2025 and diagnoses
including Infection and inflammatory reaction due to indwelling urethral catheter.
During an observation on 4/8/2025 at 11:00 AM, Enhanced Barrier Precautions (EBP) signage was
observed on Resident #254's door that read, Enhanced Barrier Precautions - everyone must: clean their
hands, including before entering and when leaving the room. Providers and staff must also wear gloves and
a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring,
changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: Central
line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. Do
not wear the same gown and gloves for the care of more than one person. (Photographic evidence
obtained) Personal Protective Equipment (PPE) - gloves, gown or mask) was stored beside the resident's
room.
During an observation on 4/8/2025 at 11:00 AM, Registered Nurse (RN) A initiated Cefepime HCL
(hydrochloride) solution 50 ml (milliliters) intravenously (IV) via pump over 1 hour and did not adhere to
Enhanced Barrier Precautions (EBP). She did not utilize PPE (gloves, gown or mask).
During an observation on 4/8/2025 at 11:59 AM RN A discontinued IV infusing of Cefepime HCL solution
and flush PICC (Peripherally inserted Central Catheter) line with 10 cc (cubic centimeters) Normal Saline
(NS) solution and did not adhere to EBP. RN A did not use PPE.
A review of Resident #254's physician orders dated 4/1/2025 read, Enhanced barrier precautions every
shift.
2. A review of Resident #305's medical record revealed an admission on [DATE] with diagnoses inlcuding
endocarditis and pneumonia.
During an observation on 4/8/2025 at 12:10 PM, RN A initiated Daptomycin 600 mg (milligrams)/100 ml
(milliliters) NS over 30 minutes at 200 ml/hour via pump every 24 hours for bacteremia observed being
initiated at 12:10 PM and RN A flushed the IV at the left AC (antecubital) with 10 cc NS prior to
administration of Daptomycin IV. RN A did not adhere to physician's orders for EBP and did not utilize PPE.
During an observation on 4/8/2025 at 12:10 PM, RN A discontinued the G-tube (feeding tube passed into a
resident's stomach through the abdominal wall) feeding and flushed the G-tube after aspiration of contents
with 200 cc of tap water. RN A did not adhere to physician's orders for EBP. She did not utilize PPE.
A review of Resident #305's physician's orders, dated 4/2/2025, read, Enhanced Barrier Precautions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 10 of 11
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
04/10/2025
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A review of Resident #305's Physician's orders, dated 4/3/2025, read, Daptomycin intravenous solution
reconstituted 600 mg one time a day everyday time code 08:00 (8:00 AM), use 600 mg intravenously one
time a day for bacteremia until 4/22/2025 at 23:59 (11:59 PM)
During an interview on 4/9/2025 at 12:20 PM with RN A, she stated, I should have put on mask, gloves and
gown for [Resident # 254 and Resident #305] prior to administering their IV medications and stopping and
flushing the G-tube for [Resident #305]. I just didn't think to do it.
During an interview on 4/8/2025 at 12:40 PM with Licensed Practical Nurse (LPN) B/Nurse Manager, she
stated when staff were providing direct care to residents with IV's, G-tubes, or for any reason the resident
was on EBP, gowns and gloves had to be worn.
During an interview on 4/8/2025 at 12:58 PM with the Director of Nursing, she stated for any resident that
had an IV or G-tube, staff must use PPE when providing direct care even if an EBP sign was not posted.
During an interview on 4/9/2025 at 9:49 AM with the Assistant Director of Nursing, she stated EBP was
utilized when any staff member was providing direct care for any resident that had an IV or G-tube. EBP
included using a gown and gloves when providing direct care.
A review of the facility's policy and procedure titled Enhanced Barrier Precautions (dated 1/30/2025)
revealed: It is the policy of this facility to implement enhanced barrier precautions for the prevention of
transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions refers to the use of
gown and gloves during high-contact resident care activities for residents known to be colonized or infected
with a MDRO as well as for those at increased risk of MDRO acquisition (e.g., residents with wounds or
indwelling medical devices) . 4. High- contact resident care activities include: . g. Device care or use: central
lines . 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the
facility or until the wound heals or indwelling medical device is removed.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105816
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the April 10, 2025 survey of LILAC AT BAYVIEW, THE?
This was a inspection survey of LILAC AT BAYVIEW, THE on April 10, 2025. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LILAC AT BAYVIEW, THE on April 10, 2025?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as neede..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.