Cycle 1
Health 2025-08-14 · Fire 2025-08-14
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Lake City, FL
Baya Pointe Nursing And Rehabilitation Center
1-star overall rating with 1-star inspections with $157,180 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
587 Se Ermine Ave, Lake City, FL
(386) 752-7800
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aston Health
Operator or chain grouping
Approved since
1994-01-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
91%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,288
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.38% · Performance 23.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.28
Baseline 8.49% · Performance 7.86% · Measure score 1.28 · Achievement 0 · Improvement 1.28
Total nurse turnover
0
Baseline 65.52% · Performance 64.05% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.47
Baseline 3.56 hours · Performance 3.49 hours · Measure score 1.47 · Achievement 1.47 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 14.41% · Lower 95% interval 8.28% |
| Discharge to community | 48.66% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 41.46% · Lower 95% interval 37.74% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99% |
95.27%
3.7 pts better
|
Numerator 99 · Denominator 100 |
| Falls with major injury | 1% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 100 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 28 · Denominator 49 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 28 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 2 · Denominator 100 · Adjusted rate 1.56% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 10% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 59.18% |
56.45%
2.7 pts better
|
Numerator 29 · Denominator 49 |
| Transfer of health information to provider | 97.73% |
95.95%
1.8 pts better
|
Numerator 43 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
97.8%
1.4 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 98.5% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.6%
0.1 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 3.1% · Q4 1.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.9%
1.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 2.0% · Q3 3.7% · Q4 0.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
15.7%
1.1 pts worse
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 14.5% · Q3 14.3% · Q4 19.0% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
9.8%
7.6 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 11.1% · Q3 21.4% · Q4 22.9% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.8% |
11.7%
2.9 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q3 12.2% · Q4 3.3% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
9.8%
4.6 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 9.6% · Q3 2.0% · Q4 3.6% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.1% |
12.5%
1.4 pts better
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 14.7% · Q3 9.7% · Q4 4.8% · 4Q avg 11.1% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.1%
1.6 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 3.1% · Q4 3.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
94.3%
4.9 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.3% · Q4 98.2% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
9.3%
0.1 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 10.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 1.4% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
94.7%
4.5 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.1% |
26.2%
6.9 pts worse
|
23.9%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.1% · Observed 33.3% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-10 · Fire 2024-05-10
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
7 health deficiencies
Top issue: Administration (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-23
F · Potential for more than minimal harm
2024-05-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-13
F · Potential for more than minimal harm
2024-05-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-13
E · Potential for more than minimal harm
2023-09-14
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-12
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-02-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-17
D · Potential for more than minimal harm
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-06-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-05-10
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-05-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-05-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-13
K · Immediate jeopardy
2023-07-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-31
K · Immediate jeopardy
2023-07-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-31
K · Immediate jeopardy
2023-07-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-31
K · Immediate jeopardy
2023-07-07
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-07-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-01-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-21
Penalties and ownership
What sits behind the stars
$157,180
2023-07-07
Fine
Fine · fine $157,180
Fine
Ownership
Baya Pointe Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Friedman, Leopold
5% Or Greater Indirect Ownership Interest · Individual
Gutman, Samuel
5% Or Greater Indirect Ownership Interest · Individual
Aston Healthcare LLC
Operational/Managerial Control · Organization
Franklin, Heather
Operational/Managerial Control · Individual
Martinez Irizarry, Axel
Operational/Managerial Control · Individual
Russell, Alexander
Operational/Managerial Control · Individual
Sheppard, Lauren
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lake Montgomery Health And Rehabilitation Center
Lake City, FL
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Lake City Healthcare And Rehabilitation Center
Lake City, FL
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Solaris Healthcare Lake City
Lake City, FL
4-star overall rating with 3-star inspections with $24,850 in total fines with 6 recent health deficiencies
Jump out