Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lilac At Bayview, The during CMS and state inspections, most recent first.
A resident was admitted with a PASRR Level I indicating depressive disorder and no need for Level II screening, but later developed additional diagnoses of anxiety disorder, psychosis, and brief psychotic disorder. Despite these new findings and a psychiatry referral, the facility did not update the PASRR or initiate a Level II screening as required by policy.
A resident with a G-tube and severe malnutrition continued to receive enteral feeding past the physician-ordered stop time. Nursing staff acknowledged the feeding should have been stopped earlier, but it remained infusing due to inattention to the schedule. The facility could not provide a policy for following physician's orders when requested.
Two residents at nutritional risk did not receive physician-ordered interventions as required. Orders for daily nutritional supplements and documentation of intake were not followed, and a speech therapy referral for weight management was not completed. Staff confirmed the lack of documentation and absence of a system to flag new orders.
Two residents received intravenous antibiotics several hours later than scheduled, resulting in a medication error rate above 5%. Nursing staff admitted to routinely administering medications late, and management confirmed that facility policy requires administration within one hour of the scheduled time. The late administrations were not accompanied by physician notification, as required by policy.
Surveyors found that medications, including prescription and over-the-counter drugs, were left unsecured at the bedsides of three residents. Residents reported keeping and taking these medications on their own, and staff interviews confirmed that no residents were authorized for self-administration or provided with lock boxes. Facility policy requires all medications to be stored in locked compartments, but this was not followed.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents with indwelling devices and on antibiotics, failing to use required PPE such as gloves and gowns during high-contact care activities like IV medication administration and G-tube management, despite physician orders and facility policy. Nursing staff and leadership confirmed that EBP should have been implemented in these situations.
A facility failed to implement a comprehensive care plan for a cognitively impaired resident, resulting in inadequate monitoring and documentation. The resident, involved in an incident with another cognitively impaired resident, was supposed to be monitored every 15 minutes as per physician's orders. However, staff interviews and observations revealed inconsistencies in performing and documenting these checks, and the Director of Nursing could not provide the necessary records. The deficiency was further highlighted by staff passing the resident's room without conducting the required checks.
A facility failed to implement its QAPI plan effectively, leading to an incident where two cognitively impaired residents were found in a compromising situation. The QAPI committee identified a lack of discussion about intimate relations as a root cause, but this was not addressed in the admissions process. Interviews revealed inconsistencies in handling the situation and oversight in addressing RCA findings.
A resident with moderate cognitive impairment was abruptly discharged from a facility due to smoking policy violations, despite being on 1:1 supervision and demonstrating safe smoking practices. The discharge was executed without adequate notice or involvement of the resident's Power of Attorney, leading to a traumatic transfer 203 miles away. The facility's actions were inconsistent with their discharge planning policy, causing distress to the resident and her family.
A resident with moderate cognitive impairment was abruptly discharged from a facility without proper involvement of her or her POA in the discharge planning process. Despite being issued a 30-day notice for violating smoking rules, the facility initiated an emergency discharge just four days later, moving the resident 203 miles away. The resident and her family were not adequately informed or involved in selecting a post-discharge provider, leading to significant emotional distress.
Failure to Initiate Level II PASRR for Resident with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with newly identified or possible serious mental disorders was properly reviewed for a Level II Pre-Admission Screening and Resident Review (PASRR). Record review showed that the resident was admitted with a PASRR Level I from the hospital indicating depressive disorder and no need for Level II screening. However, subsequent documentation at the facility included additional diagnoses of anxiety disorder, psychosis, and brief psychotic disorder. The resident's admission summary also noted a history of depression, dementia, and other medical conditions, and a psychiatry referral was made for evaluation and treatment of depression, anxiety, dementia, and psychosis. Despite these new or newly evident psychiatric diagnoses, the facility did not update the Level I PASRR to reflect the changes or initiate a Level II PASRR screening as required. The Director of Nursing confirmed that there was no documentation indicating that the PASRR had been revised or that a Level II screening had been started. Facility policy requires prompt referral for Level II review when a resident exhibits behavioral, psychiatric, or mood-related symptoms suggesting a mental disorder, but this process was not followed in this case.
Failure to Follow Physician's Orders for Enteral Feeding
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders regarding the administration of enteral feeding for a resident with severe protein-calorie malnutrition, dysphagia, and a gastrostomy tube. The physician's order specified that Jevity 1.5 should be administered via G-tube at 40 ml/hr, starting at 2:00 PM and stopping at 10:00 AM daily, with an autoflush every hour for four hours. However, during an observation at 12:10 PM, the enteral feeding was still infusing, contrary to the order to stop at 10:00 AM. Interviews with nursing staff, including an RN, an LPN/Nurse Manager, and the Director of Nursing, confirmed that the feeding should have been stopped at 10:00 AM as per the physician's order. The RN admitted to not paying attention to the time, resulting in the feeding continuing past the ordered stop time. The facility was unable to provide a policy and procedure for following physician's orders when requested during the survey.
Failure to Implement and Document Physician-Ordered Nutritional Interventions
Penalty
Summary
The facility failed to implement physician-ordered nutritional interventions for two residents identified as being at nutritional risk. For one resident with a history of autoimmune gastritis, dysphagia, and significant weight loss, the care plan included a mechanically altered diet and a physician's order for a daily nutritional supplement with documentation of the amount consumed. However, records did not show that the amount of supplement consumed was documented as ordered. Additionally, a physician's order for a speech therapy consult related to weight management was not carried out, and there was no documentation of a referral or evaluation by speech therapy. Interviews with staff confirmed that the orders were not followed, and there was no system in place to flag new physician orders for follow-up. For another resident at risk for altered nutrition due to psychotropic medication use and recent weight loss, a similar physician's order for a daily nutritional supplement with documentation of intake was not followed. Medication and treatment administration records did not include the required documentation of supplement consumption. Staff interviews confirmed the lack of compliance with the physician's orders for both residents.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.45% during the survey period. Specifically, two residents were observed receiving their prescribed intravenous antibiotics significantly later than scheduled. For one resident, Cefepime HCL was ordered to be administered every 12 hours for a urinary tract infection, with a scheduled dose at 9:00 AM. However, the medication was administered at 11:00 AM, two hours late. The nurse responsible acknowledged routinely administering medications late and incorrectly stated the frequency of administration. Another resident was prescribed Daptomycin to be administered intravenously every 24 hours for bacteremia, scheduled at 8:00 AM. The medication was given at 12:10 PM, four hours late. The nurse again admitted to consistently administering medications late. Interviews with nursing management confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time, and any deviation outside this window is considered late. Review of the facility's policy corroborated this standard, and there was no documentation of physician notification for the late administrations.
Unsecured Medications Found in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of drugs and biologicals in accordance with professional standards. Unsecured medications were found in the rooms of three residents across two hallways. In one instance, two bottles of medication labeled Prevagen and Cerebral were repeatedly observed at the bedside of a resident, who confirmed he had kept and taken these pills daily for months. In another case, a medication cup containing seven unidentified pills was found on a resident's bedside table; the resident stated these were his morning medications, which he delayed taking until after eating. The LPN and Unit Manager both confirmed that medications, including over-the-counter drugs, are not permitted in resident rooms unless the resident has been assessed for self-administration and provided with a lock box, which was not the case here. Additionally, a medication cup with an unidentifiable pink pill was found unsecured on another resident's bedside table. The resident stated that medications were routinely left at the bedside until food was available. Review of this resident's medical record showed no assessment for self-administration of medication. Interviews with nursing staff and the DON confirmed that no residents were authorized to have medications at bedside and that all medications should be administered under direct observation or stored securely. The facility's own policy requires all medications to be stored in locked compartments and not left unattended, which was not followed in these instances.
Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring staff adhered to Enhanced Barrier Precautions (EBP) for two residents who were at increased risk of infection due to the presence of indwelling medical devices and ongoing antibiotic therapy. For one resident with an indwelling urethral catheter and a diagnosis of infection and inflammatory reaction, staff did not use required personal protective equipment (PPE) such as gloves and gowns while administering and discontinuing intravenous antibiotics and flushing a PICC line, despite clear signage and physician orders for EBP. Similarly, another resident with diagnoses including endocarditis and pneumonia, and who had a G-tube and was receiving intravenous antibiotics, did not receive care in accordance with EBP. The registered nurse failed to use PPE while administering IV medications, flushing the IV, and managing the G-tube, contrary to physician orders and facility policy. Interviews with nursing staff and leadership confirmed that PPE should have been used during these high-contact care activities, and the facility's policy required EBP for residents with indwelling devices or wounds.
Failure to Implement Comprehensive Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan to ensure the medical, physical, and psychosocial needs of a cognitively impaired resident were met, resulting in a deficiency. The incident involved a female resident with severe cognitive impairment who was found in bed with a male resident, also severely cognitively impaired. Both residents were placed on 1:1 supervision following the incident, but the care plan was not updated to reflect the physician's order for every 15-minute monitoring checks. The facility's documentation and monitoring practices were inadequate, as evidenced by the lack of 15-minute monitoring logs for the resident after a certain date. Interviews with staff revealed inconsistencies in the understanding and execution of the monitoring requirements. A Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) both indicated that they were not consistently performing or documenting the required checks, and the Director of Nursing (DON) was unable to produce the necessary documentation when requested. Observations further highlighted the deficiency, as staff were seen passing by the resident's room without conducting the required checks. The room's layout, with a curtain obscuring the view, compounded the issue, as it allowed for the possibility of unmonitored activity. Despite claims from staff that checks were being performed, the lack of documentation and direct observation indicated otherwise, leading to the conclusion that the facility failed to adequately implement the care plan and ensure the resident's safety.
Failure to Implement QAPI Plan and Address Resident Intimacy
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) plan effectively, particularly in using data for Root Cause Analysis (RCA) to prevent future adverse events. This deficiency was highlighted by an incident involving two residents with severe cognitive impairments who were found in a compromising situation. The facility's investigation revealed that the residents were allegedly engaged in sexual intercourse, with one resident having a BIMS score indicating severe cognitive impairment and the other initially assessed as cognitively intact but later found to have severe impairment as well. The incident occurred when a CNA discovered the two residents in bed together, leading to immediate 1:1 supervision for both. Despite the facility's response to the incident, the QAPI committee's RCA identified a lack of discussion about intimate relations as a root cause, which was not addressed in the admissions process. The facility's failure to incorporate this into their QAPI plan and educate residents on intimate relations contributed to the deficiency. Interviews with staff and the Regional Director of Operations (RDO) revealed inconsistencies in the facility's handling of the situation and the QAPI committee's oversight in addressing the RCA findings. The RDO acknowledged the need for resident education on intimate relations but admitted that no changes were made to the admissions process. The facility's policies on abuse prevention and QAPI were not effectively implemented, leading to a failure in preventing and addressing the incident adequately.
Abrupt Discharge Due to Smoking Policy Violation
Penalty
Summary
The facility failed to provide sufficient preparation and orientation for a safe and orderly discharge of a resident, leading to a traumatic and abrupt transfer. The resident, who had a history of non-compliance with the smoking policy, was initially given a 30-day notice for discharge due to smoking violations. However, this notice was rescinded, and the resident was informed of an immediate discharge due to endangering other residents by smoking near a resident on oxygen. Despite being placed on 1:1 supervision and demonstrating safe smoking practices thereafter, the resident was abruptly discharged to a facility 203 miles away, causing distress to both the resident and her family. The resident, who had moderate cognitive impairment and was mostly independent in daily activities, was discharged without adequate notice or involvement in the discharge planning process. The facility's actions were inconsistent with their discharge planning policy, which emphasizes resident participation and preparation for discharge. The resident's son, who was the Power of Attorney, was not adequately informed or involved in the discharge decision, and the resident was transferred without the opportunity to say goodbye to her husband, who was also a resident at the facility. Interviews with the resident, her family, and facility staff revealed a lack of communication and coordination in the discharge process. The facility's administrator and Director of Nursing cited safety concerns as the reason for the immediate discharge, but the resident's family and the Long-Term Care Ombudsman were not adequately informed or consulted. The facility's failure to adhere to its own discharge planning policy and the abrupt nature of the discharge caused significant trauma to the resident and her family.
Failure to Involve Resident and Family in Discharge Planning
Penalty
Summary
The facility failed to involve a resident and her representative in the discharge planning process, leading to an abrupt and traumatic discharge. The resident, who had moderate cognitive impairment and was her own responsible party, was issued a 30-day notice of discharge for violating smoking rules. Despite this, the facility initiated an emergency discharge just four days later, without providing the resident or her Power of Attorney (POA) with adequate information or options for alternative discharge locations. The resident was moved to a facility 203 miles away, causing distress to her and her family. The facility's actions were inconsistent with their discharge planning policy, which emphasizes involving residents and their representatives in selecting post-discharge providers. The resident's son, who was also her POA, was not informed of the discharge until after it had occurred, and the resident was not given the opportunity to say goodbye to her husband. The facility's staff, including the Administrator and Director of Nursing (DON), failed to ensure that the resident's preferences and needs were considered in the discharge process. Interviews with the resident, her husband, and her son revealed that the discharge was handled in a manner that was perceived as abrupt and insensitive. The resident's husband described the experience as traumatic, and the son expressed frustration with the facility's lack of communication and disregard for the family's wishes. The facility's failure to adhere to its own policies and procedures resulted in a deficiency in the discharge planning process, causing significant emotional distress to the resident and her family.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Augustine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Augustine Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 2 | 2 |
| Ponce Therapy Care Center And Rehab, The | 1.7 mi | ★★★★★ | 0 | 0 |
| Moultrie Creek Nursing And Rehab Center | 5 mi | ★★★★★ | 0 | 0 |
| Clyde E Lassen State Veterans Nursing Home | 11 mi | ★★★★★ | 0 | 0 |
| Westminster St Augustine | 12.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.