SeniorHomeViolations
B
75/100

LILAC AT BAYVIEW, THE Inspection Report, Violations & Safety Grade (SAINT AUGUSTINE, Florida)

161A MARINE STREET, SAINT AUGUSTINE, Florida 32084

Phone: 9048293475

CMS Overall:4/5

Overview & Bed Count

Certified Beds
120
Avg Residents/Day
111.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
St. Johns
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health3/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityFlorida AvgDifference
RN Hours per Resident per Day0.330.73-0.40
Total Nurse Hours per Resident per Day3.683.86-0.18
CMS Staffing Rating2/53.3/5-
Nursing Staff Turnover63.0%41.5%-

Health Citation History

19 health citations on record

DateCategoryDescriptionSeverity
2025-04-10Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2025-04-10Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2025-04-10Quality of Life and Care DeficienciesProvide enough food/fluids to maintain a resident's health.D – Moderate Harm Potential
2025-04-10Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2025-04-10Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2025-04-10Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-12-04Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2024-12-04Administration DeficienciesSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.D – Moderate Harm Potential
2024-05-17Resident Rights DeficienciesPrepare residents for a safe transfer or discharge from the nursing home.G – Actual Harm
2024-05-17Resident Assessment and Care Planning DeficienciesPlan the resident's discharge to meet the resident's goals and needs.G – Actual Harm
2023-05-18Resident Rights DeficienciesHonor 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.E – Moderate Harm Potential
2023-05-18Nutrition and Dietary DeficienciesProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.E – Moderate Harm Potential
2023-05-18Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2023-05-18Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2023-05-18Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-05-18Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2023-05-18Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2021-09-16Environmental DeficienciesKeep all essential equipment working safely.F – Moderate Harm Potential
2021-09-16Resident Rights DeficienciesHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.D – Moderate Harm Potential

Fire Safety Citation History

7 fire safety citations on record

DateCategoryDescriptionSeverity
2025-04-10Egress DeficienciesHave exits that are accessible at all times.D – Moderate Harm Potential
2025-04-10Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.D – Moderate Harm Potential
2023-05-18Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2023-05-18Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.F – Moderate Harm Potential
2023-05-18Smoke DeficienciesHave an alternate power supply for its alarm system.E – Moderate Harm Potential
2023-05-18Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.E – Moderate Harm Potential
2023-05-18Gas, Vacuum, and Electrical Systems DeficienciesEnsure that testing and maintenance of electrical equipment is performed.E – Moderate Harm Potential

Total Penalties & Fines

$16,801
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
DateTypeFine AmountPayment Denial
2024-05-17Fine$8,400-
2024-05-17Fine$8,401-

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