C-
55/100Lilac Manor Rehabilitation and Nursing Center Inspection Report, Violations & Safety Grade (Rochester, New York)
3 Upton Park, Rochester, New York 14607
Phone: 5856852525
CMS Overall:1/5
Overview & Bed Count
Certified Beds
200
Avg Residents/Day
122.6
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
Monroe
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | New York Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.74 | 0.73 | +0.01 |
| Total Nurse Hours per Resident per Day | 3.73 | 3.69 | +0.04 |
| CMS Staffing Rating | 3/5 | 2.9/5 | - |
| Nursing Staff Turnover | 62.2% | 40.3% | - |
Health Citation History
38 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-13 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2026-05-15 | 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. | E – Moderate Harm Potential |
| 2026-05-15 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | E – Moderate Harm Potential |
| 2025-08-20 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-06-06 | 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. | E – Moderate Harm Potential |
| 2024-06-06 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | E – Moderate Harm Potential |
| 2024-06-06 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | E – Moderate Harm Potential |
| 2024-06-06 | 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. | E – Moderate Harm Potential |
| 2024-06-06 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | E – Moderate Harm Potential |
| 2024-06-06 | Environmental Deficiencies | Keep all essential equipment working safely. | E – Moderate Harm Potential |
| 2024-06-06 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2024-06-06 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | D – Moderate Harm Potential |
| 2024-06-06 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2024-06-06 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-06-06 | Quality of Life and Care Deficiencies | Assist a resident in gaining access to vision and hearing services. | D – Moderate Harm Potential |
| 2024-06-06 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2024-06-06 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-06-06 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-06-06 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D – Moderate Harm Potential |
| 2024-06-06 | Administration Deficiencies | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | D – Moderate Harm Potential |
| 2024-06-06 | Resident Rights Deficiencies | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | B – Minimal Harm Potential |
| 2024-06-06 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | B – Minimal Harm Potential |
| 2024-06-06 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | B – Minimal Harm Potential |
| 2024-06-06 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | B – Minimal Harm Potential |
| 2023-02-08 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2023-02-08 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2023-02-08 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2023-02-08 | Resident Rights Deficiencies | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | B – Minimal Harm Potential |
| 2023-02-08 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | B – Minimal Harm Potential |
| 2021-04-23 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2021-04-23 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2021-04-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2021-04-23 | 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. | D – Moderate Harm Potential |
| 2021-04-23 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2021-04-23 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | D – Moderate Harm Potential |
| 2021-04-23 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2021-04-23 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2021-04-23 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D – Moderate Harm Potential |
Fire Safety Citation History
5 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-06-06 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | C – Minimal Harm Potential |
| 2024-06-06 | Emergency Preparedness Deficiencies | Develop Emergency Preparedness policies and procedures. | C – Minimal Harm Potential |
| 2024-06-06 | Emergency Preparedness Deficiencies | Provide family notifications of emergency plan. | C – Minimal Harm Potential |
| 2024-06-06 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | C – Minimal Harm Potential |
| 2024-06-06 | Emergency Preparedness Deficiencies | Meet the requirements of an integrated health system. | C – Minimal Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-06-06 | Payment Denial | - | 73 days starting 2024-09-06 |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Rochester area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.