Facility Watch Inspection records for every certified US nursing home

Lilac Manor Rehabilitation and Nursing Center

3 Upton Park
Rochester, NY 14607
(585) 685-2525

CCN
335488
Certified beds
200
Ownership
For profit - Individual

Nurse staffing

4.63
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.75 hours per resident per day

Nursing staff turnover: 66% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected August 20, 2025

1 citation · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected October 15, 2025

Inspected June 6, 2024

20 citations · from a complaint investigation · Health
B
F0577 No actual harm with potential for minimal harm · Pattern

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Deficient, Provider has date of correction · corrected August 5, 2024
B
F0582 No actual harm with potential for minimal harm · Pattern

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Deficient, Provider has date of correction · corrected August 5, 2024
B
F0655 No actual harm with potential for minimal harm · Pattern

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected August 5, 2024
B
F0732 No actual harm with potential for minimal harm · Pattern

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected September 4, 2024
D
F0578 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 5, 2024
D
F0602 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Deficient, Provider has date of correction · corrected September 4, 2024
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected August 5, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected September 4, 2024
D
F0685 No actual harm with potential for more than minimal harm · Isolated

Assist a resident in gaining access to vision and hearing services.

Deficient, Provider has date of correction · corrected August 5, 2024
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 5, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected August 5, 2024
D
F0697 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected August 5, 2024
D
F0740 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Deficient, Provider has date of correction · corrected September 4, 2024
D
F0836 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 5, 2024
E
F0584 No actual harm with potential for more than minimal harm · 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.

Deficient, Provider has date of correction · corrected September 4, 2024
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected August 5, 2024
E
F0760 No actual harm with potential for more than minimal harm · Pattern

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected September 4, 2024
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected September 4, 2024
E
F0835 No actual harm with potential for more than minimal harm · Pattern

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Deficient, Provider has date of correction · corrected September 4, 2024
E
F0908 No actual harm with potential for more than minimal harm · Pattern

Keep all essential equipment working safely.

Deficient, Provider has date of correction · corrected September 4, 2024

Inspected February 8, 2023

5 citations · Health
B
F0568 No actual harm with potential for minimal harm · Pattern

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Deficient, Provider has date of correction · corrected April 9, 2023
B
F0732 No actual harm with potential for minimal harm · Pattern

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected April 9, 2023
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected April 9, 2023
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected April 9, 2023
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected April 9, 2023

Inspected April 23, 2021

9 citations · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected June 22, 2021
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected June 22, 2021
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected June 22, 2021
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected June 22, 2021
D
F0679 No actual harm with potential for more than minimal harm · Isolated

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected June 22, 2021
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected June 22, 2021
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected June 22, 2021
D
F0921 No actual harm with potential for more than minimal harm · Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected June 23, 2021
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected June 22, 2021

Penalties

DateTypeAmount
June 6, 2024Payment Denial · 73 days