Lilac at Bayview, the
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 182 Google reviews

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (2/5 stars)
- Low staffing rating (2/5 stars)
- High staff turnover (67%)
- High RN turnover (70%)
Bottom 25% in FL · Below recommended RN staffing · $125,355 in fines
What this means for your family
While the facility offers a beautiful environment and a highly praised activities and rehab team, the recurring reports of neglect and slow response times are concerning. Families should conduct an unannounced visit during evening or weekend hours to observe staffing levels and response times firsthand before making a decision.
Google Reviews
Google Reviews
182 reviews on Google“Lilac at Bayview receives highly polarized feedback, with many families praising the facility's beautiful waterfront location, active social calendar, and specific staff members like the concierge. However, significant concerns persist regarding chronic understaffing, slow response times to call lights, and poor nutritional quality of meals. While some residents report excellent rehabilitation outcomes, others describe neglect and unprofessional administrative communication.”
Quality Themes
Tap a score for detailsStrengths
- Engaging activities and social events
- Beautiful waterfront location
- Attentive and helpful concierge staff
- Effective physical and occupational therapy
Concerns
- Slow response times to call lights and patient needs (mentioned by 9 reviewers)
- Poor quality, unnutritious, or cold food (mentioned by 7 reviewers)
- Understaffing leading to neglect or hygiene issues (mentioned by 6 reviewers)
- Unprofessional administrative and communication issues (mentioned by 5 reviewers)
- Medication management errors or delays (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 154 analyzed
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1The waterfront location looks beautiful; how do the residents typically enjoy the outdoor scenery and social events during the week?
- 2We've heard great things about the concierge staff; how does the administrative team ensure families are kept updated on their loved one's care?
- 3What steps are in place to ensure that meal service is both nutritious and served at the right temperature for every resident?
- 4How do you manage call light response times to ensure that residents' needs are met promptly, especially during busy shifts?
- 5Can you walk us through your process for medication management to ensure there are no delays or errors in administration?
- 6In the event of a medical emergency after hours, what is the protocol for notifying the family and coordinating with doctors?
Personalized based on this facility's data
Key Review Excerpts
“My brother almost died twi”
“The physical therapy however was excellent!”
“There were roaches present in patient rooms, which is completely unacceptable in a healthcare and rehabilitation setting.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
10
measures
3
measures
4
measures
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose bladder or bowel control got worse
Residents on antipsychotic medication
Residents who lost too much weight
Residents needing more daily help over time
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has significant concerns with families filing multiple complaints that triggered inspections revealing serious issues including abuse/neglect protection failures and inadequate policies to prevent harm. The most recurring problems involve care planning, medication management, and infection control, with some issues persisting across multiple surveys despite reported corrections. While all deficiencies show correction dates, the pattern of repeated violations in core care areas and family-initiated complaints suggests ongoing quality concerns that warrant careful consideration.
Apr 10, 2025Routine8
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Egress Deficiencies
Have exits that are accessible at all times.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Dec 4, 2024Complaint2
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
May 17, 2024Complaint2
Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
Sep 21, 2023Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
May 18, 2023Routine12
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Resident Rights Deficiencies
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.
Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Smoke Deficiencies
Have an alternate power supply for its alarm system.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Sep 16, 2021Routine2
Environmental Deficiencies
Keep all essential equipment working safely.
Resident Rights Deficiencies
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.
Federal Penalties
Fine
May 17, 2024
$8,400
Fine
May 17, 2024
$8,401
Fine
Sep 21, 2023
$108,554
Ownership & Operations
Who Operates This Facility
Lilac at Bayview, the
for profit
Chain Affiliation
Simcha Hyman & Naftali Zanziper
85 facilities nationwide
Chain avg rating: 2.3/5 · Rank 57 of 94
Ownership & Management
Owners
St. Augustine FL Holdco LLC
Owner · Organization
Lilac Snf Holdco LLC
Owner (parent company) · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
182 reviews from families & visitors
Official Website
Visit lilacbayview.com
Medicare data downloads
Original nursing home datasets
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