Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayview Center during CMS and state inspections, most recent first.
Unlabeled food was found stored in the main kitchen and in both nourishment rooms. Surveyors observed an employee’s unidentified food item in the walk-in refrigerator, almond milk and a griddle-wrapped sandwich without labels or dates in the first-floor nourishment area, and outside restaurant food without a label or date in the second-floor nourishment area. The CDM stated that foods should be labeled and dated, and the facility policy required outside foods to be labeled and stored separately from facility-prepared food.
Inaccurate MDS coding affected multiple residents. One resident was coded as having bed rails as restraints even though the rails were used as enablers and the resident was mobile, while other residents had MDSs that omitted a bipolar dx, anticoagulant use, and a mechanically altered diet despite physician orders. Staff acknowledged several of the coding errors.
A resident was admitted with anxiety disorder and antisocial personality disorder, but the PASRR on file did not document mental illness under Section I. A later psych note listed both diagnoses, and the DON stated the resident should have been reviewed and updated.
A resident with a g-tube was observed with the tube in place, but the chart showed no orders for tube feeding, flushes, or g-tube care for several days after the tube was dislodged and the resident was sent to the ER. Staff gave conflicting statements about whether the resident still needed the tube, whether flush orders existed, and whether the tube should be used, while the MAR also showed no tube-related entries.
Unattended medications and expired insulin were found in resident rooms and on a medication cart. An LPN found a tablet in one resident’s room even though the resident said he did not take it, a lidocaine roll-on was left in another resident’s room without an order, and a cup with pink cream was left in a third resident’s room after nurses had applied it. A hallway med cart also contained two expired Lantus vials, and staff and the DON stated medications should not be left unattended and expired meds should not remain on the cart.
The facility failed to address water intrusion in the kitchen, leading to hazardous conditions with standing water and exposed electrical outlets. Additionally, cleanliness issues in resident areas were not resolved despite a Performance Improvement Plan, and a soiled, damaged mattress was not replaced for a resident. Communication and documentation failures contributed to these deficiencies.
A water leak in the kitchen of an LTC facility led to unsafe conditions, with water dripping onto electrical equipment and the floor, creating risks of electrocution and falls. Despite staff reporting the issue to maintenance, the leak was not adequately addressed, and operations continued in the hazardous environment. Interviews revealed a lack of communication and documentation, contributing to the ongoing safety hazard.
The facility failed to maintain a safe and clean environment, with observations of dirt and debris in resident areas, a resident's mattress in poor condition, and unsecured hazardous materials. The Director of Environmental Services and other staff confirmed these issues, highlighting lapses in cleaning and maintenance procedures.
A resident with heart conditions was observed receiving oxygen at 4 liters per minute, contrary to the physician's order of 2 liters per minute. An LPN confirmed the discrepancy, and the DON stated that staff are expected to follow orders and check oxygen settings during hand-offs. The facility's policy requires adherence to physician orders and documentation of any deviations.
A CNA failed to perform hand hygiene while providing care to multiple residents, entering and exiting rooms without washing hands or after removing gloves. This was confirmed by the CNA and the DON, contradicting the facility's hand hygiene policy.
Unlabeled Food Stored in Kitchen and Nourishment Areas
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner in the main kitchen and in 2 of 2 nourishment areas. During observation, surveyors found one Styrofoam container with an unidentified food item on a shelf in the walk-in kitchen refrigerator with no label or date, and the Certified Dietary Manager stated that the food belonged to an employee and should not have been there. In the first-floor nourishment room, surveyors observed one container of almond milk with no label or date in the refrigerator and one griddle-wrapped sandwich with no label or date in the freezer; the Certified Dietary Manager stated that foods should be labeled and dated. In the second-floor nourishment room, surveyors observed one container of food/bagged from an outside restaurant with no label or date in the refrigerator, and the Certified Dietary Manager again stated that the food should be labeled and dated. The facility policy titled Outside Foods stated that food brought by family or visitors and left with the resident to consume later will be labeled and stored separately from facility-prepared food, and that food and beverages brought in must be in a resealable container or package.
Inaccurate MDS Coding for Diagnoses, Medications, Diet, and Bed Rail Use
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 6 of 10 residents reviewed. For Resident #97, the MDS dated [DATE] coded bed rails as daily physical restraints in Section P, but observation showed the resident lying in bed with 1/4 rails that were not restricting movement, and later walking in the hallway without a mobility device, using wall rails for support, then getting in and out of bed without difficulty. Staff B, the MDS Director, stated the facility did not use restraints and that coding bed rails as a restraint for this resident was inaccurate; Staff C, the MDS Coordinator, stated the P section had been completed by her and that bed rails are not restraints if the resident has mobility and can use them for positioning. For Resident #15, the quarterly MDS did not document bipolar disorder in Section I or anticoagulant use in Section N, despite diagnoses and physician orders for cariprazine/Vraylar for bipolar disorder and Xarelto for chronic atrial fibrillation. For Residents #29, #73, and #91, quarterly MDS assessments coded bed rails as daily physical restraints in Section P even though physician orders identified 1/4 side rails as enablers for bed mobility; observations showed the residents using or positioned with the rails, and Staff B stated the assessments were inaccurately coded. For Resident #19, the MDS did not show a mechanically altered diet in Section K despite an order for a regular diet with mechanical soft texture and thin consistency; Staff B stated the facility follows the RAI manual for guidance and does not have a specific MDS policy.
Failure to Update PASRR for Newly Identified Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for Resident #53, who was admitted with diagnoses including anxiety disorder and antisocial personality disorder. The resident’s PASRR dated 3/6/2026 showed no mental illness documented under Section I, PASRR Screen Decision-Making, even though a later psychiatric progress note documented antisocial personality disorder and anxiety disorder as diagnoses. During interview, the DON stated that PASRRs should be completed prior to admission and that if something is missed, the hospital would be asked for another screening; she also stated that Resident #53 should have been reviewed and updated.
Failure to Maintain Enteral Feeding Orders and Care
Penalty
Summary
The facility failed to provide appropriate enteral feeding for 1 of 3 residents reviewed for tube feeding, Resident #11. During observation on 5/14/2026 at 12:43 PM, Resident #11 had a feeding tube in place with a dressing dated 5/14/2026. Review of the admission record showed the resident was initially admitted and later readmitted, and a physician order dated 5/5/2026 directed staff to send the resident to the local hospital ER for evaluation and treatment after g-tube dislodgement. Review of the physician orders showed no orders for g-tube feeding, g-tube flush, or g-tube care from 5/6/2026 through 5/13/2026, and the MAR for May 2026 also had no entries for those services during that period. Staff interviews reflected uncertainty about the tube orders: an LPN stated the resident still had the g-tube because she goes through phases of not eating and loses weight, but then said the facility did not have orders; the RD stated she orders flushes for patency and was not aware of anyone without flush orders; the MD stated the g-tube needs to be flushed; and a unit manager stated the resident did not come back with orders for the feeding tube and that she was eating and really did not need it. The facility policy stated that if a resident has a feeding tube placed prior to admission or returning to the facility, the provider and interdisciplinary team will review the rationale, current clinical and nutritional status, and the resident's treatment goals and wishes, and that the nurse confirms enteral nutrition orders are complete.
Unattended Medications and Expired Insulin Found in Resident Areas and on Cart
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles when unattended medications were found in residents’ rooms and expired insulin remained on a medication cart. During an observation, a clear medication cup with a white tablet was found in one resident’s room, and the resident stated he did not take that medication and that it upset his stomach. An LPN later stated she was not sure where the medication came from and that the resident was not able to self-administer. In another resident’s room, a lidocaine roll-on was observed on the bedside table, while the resident said nurses helped apply it; the LPN stated there was no order for lidocaine and that the resident was not able to self-administer medications. A third resident’s room contained a clear medication cup with a pink cream, and the resident stated nurses had put it there to prevent infection. The LPN stated nurses apply zinc but it should not be left in the room. In addition, a lower hallway medication cart contained two Lantus insulin vials labeled with an expiration date that had already passed. Staff stated expired medications should not be on the cart and that carts are checked daily. The DON stated nurses should check medication carts to ensure medications are properly labeled and that there should be no expired medications on the cart. The facility policy stated drugs and biologicals must be stored in locked compartments and that outdated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed.
Failure to Address Water Intrusion, Cleanliness, and Mattress Replacement
Penalty
Summary
The facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to address significant water intrusion issues in the kitchen. Observations revealed water dripping from the kitchen ceiling into plastic bins placed on top of a convection oven and onto the floor, creating a hazardous environment with standing water and exposed electrical outlets. Despite the maintenance department being notified of the leak, no effective action was taken to resolve the issue, and the problem persisted over several days. Interviews with staff indicated a lack of communication and documentation regarding the leak, with conflicting accounts of when and how the issue was reported and addressed. Additionally, the facility did not fully implement a quality improvement plan for maintaining cleanliness and safety in resident areas. Observations on multiple occasions showed dirt, debris, and stains on the floor tiles in the resident hallway and dining room, as well as a buildup of dirt and chipped tiles and paint. The medication cart was also found to be unclean, with hair wrapped around its wheels and dark liquid streaks on its backside. Despite having a Performance Improvement Plan (PIP) in place to address these issues, the facility had not completed the necessary cleaning and maintenance tasks. Furthermore, the facility failed to replace a soiled and damaged mattress for a resident, which was observed to have cracks, sagging, and a foul urine odor. The Director of Nursing confirmed awareness of the mattress's poor condition but was unsure if maintenance had been informed. The facility's work order system showed no record of a request for mattress replacement, indicating a breakdown in communication and follow-through on maintenance needs. This deficiency highlights the facility's failure to ensure a safe and comfortable environment for its residents.
Unsafe Kitchen Conditions Due to Unresolved Water Leak
Penalty
Summary
The facility failed to maintain a safe working environment in the kitchen, where a water leak from the ceiling was observed dripping into plastic bins placed on top of a convection oven and onto the floor. This leak, which began on a Friday, was not adequately addressed, leading to standing water on the kitchen floor and on electrical equipment, posing risks of electrocution and falls. Despite the presence of staff working in the kitchen, no caution signs were placed to warn of the wet floor. Interviews with various staff members, including dietary cooks and aides, revealed that the leak was reported to maintenance shortly after it began. However, the maintenance department's response was insufficient, as the leak worsened over the weekend. The Director of Dietary Services and several staff members expressed concerns about the safety of working around water and electricity, yet operations continued in the hazardous environment. The maintenance director, who had been employed for a few months, was aware of past leaks but did not effectively communicate or resolve the current issue. Further observations showed that water was dripping from an exit sign and into an open electrical junction box, creating a potential electrocution hazard. The facility's maintenance and repair policies, which require immediate attention to emergency repairs, were not followed. Interviews with the maintenance director and other staff indicated a lack of communication and documentation regarding the leak, contributing to the unsafe conditions in the kitchen.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by multiple observations of dirt, debris, and stains in the resident areas. Specifically, the 200 Unit East Wing had dirt, debris, and dried red liquid stains on the floor tiles, chipped tiles, and paint along the door frames. The medication cart had hair wrapped around its wheels and dark dried liquid streaks on its backside. The Director of Environmental Services confirmed these observations and acknowledged that the cleaning expectations were not being met. A resident's mattress was found to be in poor condition, with a large indentation, sagging, cracks, and a foul urine odor. The CNA and DON both confirmed the mattress's condition, noting that it had been an issue for a long time and could potentially cause skin breakdown for the resident. Despite the awareness of the mattress's condition, no work order had been initiated for its replacement, as confirmed by the Director of Environmental Services. Additionally, the facility failed to secure hazardous materials properly. A housekeeping storage room door was found to be unlocked, allowing a resident to open it without entering a code. The room contained various cleaning chemicals. Furthermore, a housekeeping cart with a broken lock was left unattended, containing several cleaning agents. Staff interviews revealed that the broken locks had not been reported or addressed, indicating a lapse in communication and maintenance procedures.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that a resident received oxygen as per the physician's order. Resident #94, who was admitted with diagnoses including unspecified cardiomyopathy, hypertensive heart disease with heart failure, old myocardial infarction, and chronic systolic heart failure, had a physician's order dated 12/6/2024 for oxygen administration at 2 liters per minute as needed for shortness of breath. However, during observations on 12/10/2024, the resident was found receiving oxygen at 4 liters per minute, which was not in accordance with the physician's order. Staff H, an LPN, acknowledged during an interview that the resident's oxygen was ordered for 2 liters, not 4 liters, and mentioned that they usually check the oxygen settings when administering medications. The Director of Nursing stated that staff are expected to check oxygen settings and follow orders, especially during hand-offs. The facility's policy on physician orders emphasizes that orders should be followed as prescribed, and any deviations should be recorded in the resident's medical record, with the physician and responsible party notified if indicated.
Failure to Perform Hand Hygiene by CNA
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for infection control, specifically in performing hand hygiene while providing care for residents. During observations, a Certified Nursing Assistant (CNA), identified as Staff B, was seen entering and exiting multiple residents' rooms without performing hand hygiene. This occurred while providing personal care to residents, including assisting with personal care items and changing dirty linen. Staff B did not wash hands between rooms or after removing gloves, which is a critical step in preventing the spread of infection. Interviews conducted with Staff B and the Director of Nursing (DON) confirmed the failure to perform hand hygiene as per the facility's policy. Staff B acknowledged the oversight, stating that hand hygiene should have been performed before and after resident care. The facility's policy on hand hygiene, last revised in June 2023, emphasizes the importance of hand hygiene as the single most important measure for preventing infection spread, requiring personnel to perform hand hygiene after each direct resident contact and after removing gloves.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eustis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Eustis Healthcare And Rehabilitation Center | 0.3 mi | ★★★★★ | 10 | 2 |
| Ruleme Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Solaris Healthcare Waterman | 2.3 mi | ★★★★★ | 1 | 0 |
| Avante At Mt Dora, Inc | 2.8 mi | ★★★★★ | 11 | 0 |
| Edgewater At Waterman Village | 3.1 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.