Lilac at Bayview, The

In the surveyor’s words

From the most serious findings on record at Lilac at Bayview, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 21, 2023

  Based on observations, staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), the facility failed to provide vulnerable residents protection from sexual abuse. This resulted in nonconsensual sexual contact for one (Resident #1) of four residents reviewed for abuse. The facility failed to identify, develop, and implement interventions necessary to protect Resident #1 from nonconsensual sexual contact with Resident #2, who had moderate cognitive impairment and diagnoses including unspecified psychosis, generalized anxiety, and who was independently ambulatory. […]

• Immediate jeopardy, isolatedF607Sep 21, 2023

  Based on a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), interviews with staff, and resident and facility record reviews, the facility failed to implement its policies and procedures to protect vulnerable residents from sexual abuse by failing to 1) Identify sexual abuse following nonconsensual activity between Resident #1 (severe cognitive impairment and independently ambulatory) and Resident #2 (moderate cognitive impairment and independently ambulatory), 2) Protect Resident #1 by providing increased supervision and a room change (as alleged in the facility's response to the incident) to increase the distance between Resident #1 and Resident #2, 3) Initiate staff training on what constituted sexual abuse following the incident, 4) Modify resident care… […]

• Immediate jeopardy, isolatedF867Sep 21, 2023

  Based on observations, staff interviews, resident and facility record reviews, a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), and the facility's 2023 Quality Assurance and Performance Improvement Plan, the facility failed to identify, develop, and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes. This resulted in a lack of improvement of their systems and processes, and the failure contributed to nonconsensual sexual contact for one (Resident #1) of four residents reviewed for abuse. […]

• Immediate jeopardy, isolatedF578Jul 23, 2021

  Based on interviews and record reviews, the facility failed to honor a resident's Advance Directives by failing to verify Advance Directives prior to initiating basic life support for one (Resident #1) of four residents reviewed for Advance Directives. On [DATE] at approximately 5:15 AM, Resident #1 was discovered unresponsive by Employee A, Licensed Practical Nurse (LPN), an Agency employee. Employee B, Certified Nursing Assistant (CNA), an Agency employee, began cardiopulmonary resuscitation (CPR) on resident #1 without checking the resident's code status first. The resident had an active Do Not Resuscitate Order (DNRO). Employee A, Agency LPN, did not intervene to stop Employee B, Agency CNA, prior to her initiating CPR. […]

• Immediate jeopardy, isolatedF678Jul 23, 2021

  Based on interviews and record reviews, the facility failed to withhold basic life support measures in accordance with a resident's Advance Directives and Do Not Resuscitate Order (DNRO) for one (Resident #1) of four residents reviewed. Additionally, Agency staff were not aware of how to access the resident's information on code status. On [DATE] at approximately 5:15 AM, Resident #1 was discovered unresponsive by Employee A, Licensed Practical Nurse (LPN), an Agency employee. Employee B, Certified Nursing Assistant (CNA), an Agency employee, began cardiopulmonary resuscitation (CPR) on resident #1 without checking the resident's code status first. The resident had an active Do Not Resuscitate Order (DNRO). […]