Cycle 1
Health 2025-04-10 · Fire 2025-04-10
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Saint Augustine, FL
Lilac At Bayview, The
2-star overall rating with 2-star inspections with $125,355 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
161a Marine Street, Saint Augustine, FL
(904) 829-3475
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
1993-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
94 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 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
0.38
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.53
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
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,809
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.47
Baseline 27.06% · Performance 23.08% · Measure score 3.47 · Achievement 0 · Improvement 3.47
Healthcare-associated infections
1.24
Baseline 9.84% · Performance 9.00% · Measure score 1.24 · Achievement 0 · Improvement 1.24
Total nurse turnover
0
Performance 64.35% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.91
Baseline 4.16 hours · Performance 3.91 hours · Measure score 2.91 · Achievement 2.91 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.94% |
10.72%
5.2 pts worse
|
Worse than the National Rate · Eligible stays 299 · Observed rate 19.73% · Lower 95% interval 12.83% |
| Discharge to community | 39.73% |
50.57%
10.8 pts worse
|
Worse than the National Rate · Eligible stays 234 · Observed rate 34.62% · Lower 95% interval 35.08% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.95% |
95.27%
2.7 pts better
|
Numerator 143 · Denominator 146 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 146 |
| Discharge self-care score | 40.57% |
53.69%
13.1 pts worse
|
Numerator 43 · Denominator 106 |
| Discharge mobility score | 28.3% |
50.94%
22.6 pts worse
|
Numerator 30 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 4.79% |
2.29%
2.5 pts worse
|
Numerator 7 · Denominator 146 · Adjusted rate 4.4% |
| Healthcare-associated infections requiring hospitalization | 9% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 10.56% · Lower 95% interval 5.94% |
| Staff COVID-19 vaccination coverage | 1.28% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 156 |
| Staff flu vaccination coverage | 3.85% |
42%
38.1 pts worse
|
Numerator 6 · Denominator 156 |
| Discharge function score | 38.68% |
56.45%
17.8 pts worse
|
Numerator 41 · Denominator 106 |
| Transfer of health information to provider | 98.18% |
95.95%
2.2 pts better
|
Numerator 54 · Denominator 55 |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 40 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 3.17% |
25.2%
22 pts worse
|
Numerator 2 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
97.8%
0.9 pts worse
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 96.7% · Q3 96.7% · Q4 97.8% · 4Q avg 96.9% |
| 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 | 4.7% |
2.6%
2.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.6% · Q3 4.3% · Q4 2.2% · 4Q avg 4.7% · 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 | 12.0% |
5.9%
6.1 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 14.7% · Q3 10.0% · Q4 7.7% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
15.7%
9.2 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.7% · Q3 7.0% · Q4 7.5% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
9.8%
2.8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.8% · Q3 5.1% · Q4 5.4% · 4Q avg 7.0% · 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 | 11.4% |
11.7%
0.3 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 21.5% · Q3 5.1% · Q4 19.1% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
9.8%
1.2 pts worse
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.9% · Q3 4.5% · Q4 12.7% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.1% |
12.5%
2.4 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 13.8% · Q3 6.3% · Q4 13.5% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.1%
2.1 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.1% · Q3 2.0% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
94.3%
3.6 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 97.8% · Q3 99.2% · Q4 98.1% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
9.3%
0.8 pts worse
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 11.2% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.6% · Q3 1.6% · Q4 2.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
94.7%
1.7 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
26.2%
2.9 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 24.5% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-18 · Fire 2023-05-18
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-09-16 · Fire 2021-09-16
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-08
F · Potential for more than minimal harm
2023-05-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-18
F · Potential for more than minimal harm
2023-05-18
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-18
E · Potential for more than minimal harm
2023-05-18
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-06-18
E · Potential for more than minimal harm
2023-05-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-18
E · Potential for more than minimal harm
2023-05-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-10
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 2025-05-08
D · Potential for more than minimal harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-10
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 2025-05-08
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-08
D · Potential for more than minimal harm
2024-12-04
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 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-01-03
G · Actual harm
2024-05-17
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-06-17
G · Actual harm
2024-05-17
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-06-17
J · Immediate jeopardy
2023-09-21
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 2023-10-06
J · Immediate jeopardy
2023-09-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-06
J · Immediate jeopardy
2023-09-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-05-18
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 2023-06-18
E · Potential for more than minimal harm
2023-05-18
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-06-18
D · Potential for more than minimal harm
2023-05-18
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 2023-06-18
D · Potential for more than minimal harm
2023-05-18
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 2023-06-18
D · Potential for more than minimal harm
2023-05-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-18
D · Potential for more than minimal harm
2023-05-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-18
D · Potential for more than minimal harm
2023-05-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-18
F · Potential for more than minimal harm
2021-09-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-10-21
D · Potential for more than minimal harm
2021-09-16
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2021-10-21
Penalties and ownership
What sits behind the stars
$8,400
2024-05-17
Fine
Fine · fine $8,400
Fine
$8,401
2024-05-17
Fine
Fine · fine $8,401
Fine
$108,554
2023-09-21
Fine
Fine · fine $108,554
Fine
Ownership
St. Augustine Fl Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Gorelick, Batya
Corporate Officer · Individual
Hc Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Lake, Larry
W-2 Managing Employee · Individual
Lilac Health Group LLC
Operational/Managerial Control · Organization
Lilac SNF Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Terentev, Alex
Corporate Officer · Individual
Zanziper Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
St Augustine Health And Rehabilitation Center
Saint Augustine, FL
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Ponce Therapy Care Center And Rehab, The
Saint Augustine, FL
5-star overall rating with 5-star inspections
#3
Moultrie Creek Nursing And Rehab Center
Saint Augustine, FL
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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