Lilac at Bayview, the
161a Marine Street, Saint Augustine, FL 32084 · St. Johns County · 120 certified beds · avg 106 residents/day · certified since Jul 1, 1993
Part of chain: SIMCHA HYMAN & NAFTALI ZANZIPER (79 facilities, chain avg rating 2.6★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 21, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 6, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 21, 2023 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 6, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 21, 2023 · F-0867 · triggered by a complaint
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 6, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 17, 2024 · F-0624 · triggered by a complaint
The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.
Why it matters: An unprepared discharge can send a resident somewhere unsafe or without the care arrangements they need.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 17, 2024 · F-0660 · triggered by a complaint
The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving.
Why it matters: Poor discharge planning can send a resident home or elsewhere without the support, equipment, or follow-up care they need.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (22)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 4, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Dec 4, 2024 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| May 17, 2024 | ▲ G · Actual harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| May 17, 2024 | ▲ G · Actual harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Sep 21, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 21, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Sep 21, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| May 18, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 18, 2023 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 18, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 16, 2021 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Sep 16, 2021 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (7 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 2 | 0 | F |
| 2023 | 10 | 3 | J ▲ |
| 2024 | 4 | 2 | G ▲ |
| 2025 | 6 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $125,355.
| Date | Type | Amount / length |
|---|---|---|
| May 17, 2024 | Fine | $8,400 |
| May 17, 2024 | Fine | $8,401 |
| Sep 21, 2023 | Fine | $108,554 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Florida avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.93 | 4.03 | 3.95 | top 45% in Florida; top 43% in the U.S. |
| Registered Nurse hours | 0.40 | 0.76 | 0.69 | bottom 8% in Florida; bottom 22% in the U.S. |
| Weekend total nurse staffing | 3.61 | 3.68 | 3.50 | top 43% in Florida; top 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.18 | 0.53 | 0.48 | bottom 4% in Florida; bottom 9% in the U.S. |
| Total nursing staff turnover (%) | 65.4 | 41.4 | 45.8 | bottom 4% in Florida; bottom 9% in the U.S. |
| RN turnover (%) | 71.4 | 46.0 | 42.9 | bottom 11% in Florida; bottom 11% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.53, RN 0.36, weekend 3.24. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lilac SNF Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 01/13/2022 |
| St. Augustine FL Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/13/2022 |
| Gorelick, Batya | Individual | Corporate Officer | NOT APPLICABLE | 01/13/2022 |
| Lake, Larry | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/13/2022 |
| Lilac Health Group LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/13/2022 |
| Terentev, Alex | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "What does your discharge planning process look like, and how are families involved before a move?"
- "How do you prepare residents and families for discharge, and what support do you arrange for after they leave?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| St Augustine Health and Rehabilitation Center | 1.6 mi | Saint Augustine, FL | ★☆☆☆☆ | 1/5 | abuse |
| Ponce Therapy Care Center and Rehab, the | 1.7 mi | Saint Augustine, FL | ★★★★★ | 5/5 | |
| Moultrie Creek Nursing and Rehab Center | 5.0 mi | Saint Augustine, FL | ★★★★★ | 5/5 | |
| Clyde E Lassen State Veterans Nursing Home | 11.0 mi | Saint Augustine, FL | ★★★★☆ | 5/5 | |
| Westminster St Augustine | 12.6 mi | Saint Augustine, FL | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 105816.