Lilac At Bayview, The

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

39.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 234 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 41.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 95 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 106.4 residents a day — about 89% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 3.64 on weekdays — 11% thinner on weekends. RN hours go from 0.43 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 15 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · J2023-09-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial and/or physical harm from Resident #2. On 9/7/23 at 5:20 p.m., Certified Nursing Assistant (CNA) A discovered Residents #1 (severe cognitive impairment) and #2 (moderate cognitive impairment) in Resident #2's bed. Both residents had their…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-21 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 plans to include specific interventions and supervision/monitoring requirements in order to identify trends and the potential for future abuse, and 5) Coordinate with its Quality Assurance and Performance Improvement (QAPI)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-21 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. It also placed all other vulnerable female residents at risk for serious adverse outcomes related to potential sexual abuse from Resident #2. On 9/7/23 at 5:20 p.m., Certified Nursing Assistant (CNA) A discovered Residents #1 (severe cognitive impairment) and #2 (moderate cognitive impairment) in Resident #2's bed. Both residents had their pants down, Resident #2's penis was exposed, and his fingers were inside of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-05-17 · tag F0624 — isolated
  Prepare residents for a safe transfer or discharge from the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a record review, interviews, and facility policy and procedure review, the facility failed to provide sufficient preparation and orientation to ensure a safe and orderly discharge for one (Resident #1) of two residents reviewed for facility-initiated discharge. Resident #1 was issued a 30-day notice of discharge for failure to comply with smoking rules, which was then rescinded the next day when she (and her family) was advised she had to leave immediately due to her endangering other residents in the facility. This was after having been provided with 1:1 staff supervision and demonstrating safe smoking practices since. The result was an abrupt, spontaneous discharge to a location 203 miles away from her husband and son/Power of Attorney (POA) which resulted in trauma to the resident and her family. The findings include: A closed record review for Resident #1 revealed she was admitted to the facility on [DATE] and was [AGE] years old. She was discharged from the facility on a facility-initiated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-05-17 · tag F0660 — isolated
  Plan the resident's discharge to meet the resident's goals and needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a record review, interviews, and facility policy and procedure review, the facility failed to involve the resident and/or their representative in a discharge plan that considered resident preferences and involved the resident and representative in selecting a post-discharge provider for one (Resident #1) of two residents reviewed for facility-initiated discharges. Failure to involve the resident and her representative in selection of potential discharge locations resulted in an abrupt, spontaneous discharge to a facility 203 miles away from her husband and family member who was her Power of Attorney (POA). As a result, the resident and her family experienced trauma. The findings include: During an interview with the Administrator on 5/16/24 at 10:30 am, she stated Resident #1 was issued a 30-day notice of discharge for violating smoking rules. Resident #1 was smoking with a resident who had oxygen on and gave that resident a cigarette. The administrator explained that as soon as a smoking facility…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-10 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with newly evident or possible serious mental disorders, intellectual disability, or related conditions were reviewed for level II pre-admission screening and resident review (PASRR) for one (Resident #87) of two residents reviewed for PASRR. The findings include: A record review for Resident #87 was conducted on 04/08/25 at 6:30AM and read, PASRR signed by RN (registered nurse) on 7/03/24 from hospital with depressive d/o (disorder). No Level II needed. A review of the resident's medical diagnoses for the facility on 7/10/24 included anxiety d/o (disorder), psychosis and brief psychotic d/o. A review of the resident's admission summary, dated [DATE], read, Resident arrived via stretcher from [acute care hospital name] via Stat @ 1515 (3;15 PM). She is alert and oriented. Spanish speaking but understands and speaks limited English. DX CVA (Diagnosis cerebrovascular accident) She is a Full Code. POA (Power of Attorney) contacted for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to stop enteral feeding as ordered by the physician for one (Resident #305) of two residents reviewed for gastrostomy tube enteral feedings. The findings include: A review of Resident #305's medical record revealed an admission date of 4/1/2025 with diagnoses including severe protein-calorie malnutrition, dysphagia (difficulty swallowing) and gastrostomy status (G-tube - feeding tube passed into a resident's stomach through the abdominal wall). A review of Resident #305's physician's orders, dated 4/7/2025, read, Enteral feed order every shift for nutritional support administer Jevity 1.5 40 ml/hr (milliliters/hour) via G-tube continuously with (200 ml) autoflush every hour for (4) hours (1200). 20 hours a day. Start infusion daily at (1400 p) and stop infusion at (10:00 a). Ensure to record amount infused to record amount infused per pump reading once a shift. During an observation on 4/8/2025 at 12:10 PM, Jevity 1.5 Cal/Fiber Oral Liquid (Nutritional Supplement) was observed infusing at 40 ml via G-tube. During…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure nutritional interventions were implemented as ordered by the physician for two (Residents #94 and #89) of nine residents reviewed for nutrition. The findings include: 1. A review of Resident #94's care plan, revised 3/9/2025, revealed the resident was at nutritional risk related to therapeutic mechanically altered diet and autoimmune gastritis weight loss in 90 days. A review of Resident #94's weight record revealed that on 3/5/2025, Resident #94 weighed 170 pounds, and on 4/1/2025, he weighed 165.5 pounds, which was a - 2.65 % weight loss. Resident #94's weight record showed that on 11/6/2024, he weighed 204 pounds, and on 4/1/2025, he weighed 165.5 pounds, which was a - 18.87 % weight loss. A review of Resident #94's physician's orders revealed that he had a physician's order, dated 3/20/2025, which read, (Name of supplement) one time a day 120 ml (milliliters) one time a day PO (by mouth), record amount consumed. A review of Resident #94's medication administration and treatment administration records, dated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-10 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not 5% or greater for two (Residents #254 and #305) of seven residents observed during medication administration, resulting in a medication error rate of 6.45%. The findings include: 1. During medication administration observation for Resident #254 on 4/8/2025 beginning at 11:00 AM, Registered Nurse (RN) A verified orders, prepared and initiated Cefepime HCL (hydrochloride - antibiotic) solution 50 ml (milliliters) intravenously (IV), and initiated instillation via pump over 1 hour. Medication was due at 9:00 AM and was administered 2 hours late. A review of Resident #254's physician's orders, dated 4/8/2025, read, Cefepime HCL Solution 1 GM/50ML (grams per milliliters), Use 1 gram intravenously every 12 hours for UTI (urinary tract infection)for 7 Days. A review of the resident's April 2025 Medication Administration Record (MAR) revealed, Cefepime HCL Solution 1 GM/50ML, Use 1 gram intravenously every 12 hours for UTI for 7 days start date 4/8/2025 at 0900. During an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-10 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were properly stored in accordance with professional standards of practice. Unsecured medications were found on two of four hallways and affected three residents (Residents #55, #52, and #73). The findings include: 1. During an observation on 4/7/2025 at 10:49 AM of Resident #55's room, two bottles of medication were observed sitting at bedside unsecured. The bottles were labeled: Prevagen and Cerebral. (Photographic evidence obtained) During an observation on 4/8/2025 at 8:13 AM of Resident #55's room, two bottles of medication were observed sitting at bedside unsecured. The bottles were labeled: Prevagen and Cerebral. (Photographic evidence obtained) During an interview on 4/8/2025 at 8:13 AM, the resident stated he took Prevagen and Cerebral pills daily and had done so for months. He stated he had the pills in his room for months. 2. During an observation on 4/7/2025 at 11:19 AM of Resident #52's room, a medication cup with 7 unidentified pills was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-10 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure the staff followed Enhanced Barrier Precautions (EBP) for two (Residents #254 and #305) of seven residents reviewed for infection with use of antibiotics. The findings include: 1. A review of Resident #254's medical record revealed an admission date of 3/28/2025 and diagnoses including Infection and inflammatory reaction due to indwelling urethral catheter. During an observation on 4/8/2025 at 11:00 AM, Enhanced Barrier Precautions (EBP) signage was observed on Resident #254's door that read, Enhanced Barrier Precautions - everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-04 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to implement the comprehensive care plan to ensure the resident's medical, physical and psychosocial needs were met and failed to ensure a cognitively impaired resident's right to be free from abuse, including sexual abuse, was implemented for one (Resident #2) of 4 residents reviewed for resident-to-resident abuse, from a total sample of 7 residents. The findings include: A review of a facility federal report generated on 11/18/24 by the Regional Director of Operation (RDO) revealed on 11/9/24 at 7:00 pm, Resident #2, a [AGE] year-old female who had been admitted the day before (11/8/24), was found in bed with Resident #3, a [AGE] year-old male. Resident #2 and #3 were allegedly having sexual intercourse. Resident #2 was noted to have a brief interview for mental status (BIMS) score of 3 out of 15 points, indicating severe cognitive impairment. Resident #3's BIMS was noted as 0 in the report (indicating severe cognitive impairment). In…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-04 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility investigation report review, interviews, and facility's Quality Assurance and Performance Improvement (QAPI) policy review, the facility failed to implement it's written policies and procedures outlined in the Quality Assurance and Performance Improvement (QAPI) plan and failed to use data contributing to the Root Cause Analysis (RCA) of an adverse event to develop relevant activities to prevent similar future events. This had the potential to affect not only 1 (Resident #2) of 4 residents reviewed for resident-to-resident abuse but all cognitively impaired resident residing in or admitted to the facility. The findings include: A review of a facility federal report authored by the Regional Director of Operation (RDO) revealed on 11/9/24 at 7:00 pm, Resident #2, a [AGE] year-old female who had been admitted the day before (11/8/24), was found in bed with Resident #3, a [AGE] year-old male. Resident #2 and #3 were allegedly having sexual intercourse. Resident #2 was noted to have a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-05-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility document review, the facility failed to maintain a safe and sanitary living environment for 31 of 103 current residents, as evidenced by water damage in the ceilings from leaks in the roof in four resident rooms (rooms 101, 404, 407, and 408), water damage to the carpet and ceiling tiles in the hallway outside of the rehabilitation gym, missing or damaged floor tiles in seven resident rooms (rooms 205, 403, 404, 407, 408, 410, and 411) and the shower room on the 400 hall, damage to the walls in three resident rooms (rooms [ROOM NUMBER]), a light out in one resident bathroom (room [ROOM NUMBER]), an air conditioning unit unattached from the wall in one resident room (room [ROOM NUMBER]), and a broken window screen in the shower room on the 400 hall. The findings include: During multiple tours of the facility from 05/15/2023 through 05/18/2023, physical environment concerns were identified as follows: In room [ROOM NUMBER] on 05/16/2023 at 1:58 PM, the air…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-05-18 · tag F0802 — failed to prepare enough nourishing food — pattern
  Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed provide sufficient kitchen staff with the appropriate competencies and skills sets to carry out the functions of food and nutrition service. Failure to ensure that dietary staff were trained and knowledgeable about the proper procedures for food safety and sanitation had the potential to negatively impact all residents who received meals from the kitchen. The findings include: A kitchen tour was conducted on 05/17/23 at 11:00 a.m. There were two cooks in the kitchen at the time of the tour. [NAME] I was asked to explain the food thermometer calibration process. She replied, A glass of ice water and the thermometer should read above 80°F. When asked, what should the thermometer read to ensure the thermometer is working accurately. She replied, above 80°F. When asked, what training she had been provided in the kitchen or food safety and sanitation. [NAME] I replied, I've been employed with the facility only seven months but received kitchen training from my previous job. [NAME] J was also asked to explain the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$125,355 in federal fines across 3 penalties.

• $8,400 — penalty dated 2024-05-17
• $8,401 — penalty dated 2024-05-17
• $108,554 — penalty dated 2023-09-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $3.5M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL