Lilac Manor Rehabilitation and Nursing Center
Open-data reference.
Lilac Manor Rehabilitation and Nursing Center is a for profit - individual facility in Rochester, NY with 200 certified beds and a 1-star overall CMS rating. The facility has 36 deficiency records on file.
3 Upton Park, Rochester, NY 14607
Phone: 5856852525
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 335488
- Ownership
- For profit - Individual
- Provider Type
- Medicare and Medicaid
- Beds
- 200
- Residents
- 122
- In Hospital
- No
- County
- Monroe
- Last Inspection
- Jun 6, 2024
Staffing Data
- RN Hours
- 0.64 (nat'l avg: 0.68)
- LPN Hours
- 1.04
- CNA Hours
- 2.26
- Total Nursing Hours
- 3.94 (nat'l avg: 3.89)
- PT Hours
- 0.13
- Nursing Turnover
- 69.6%
- RN Turnover
- 85.2%
What the CMS Record Reveals About Lilac Manor Rehabilitation and Nursing Center
Lilac Manor Rehabilitation and Nursing Center operates 200 certified beds in Rochester, NY with approximately 122 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (3★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 36 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.94 total nursing hours per resident day (national average 3.89), with RN coverage at 0.64 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Individual" ownership and operating as a "Medicare and Medicaid" provider, Lilac Manor Rehabilitation and Nursing Center falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 69.6%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (36 most recent)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Oct 15, 2025
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.
Category: Administration Deficiencies
Corrected: Aug 5, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Sep 4, 2024
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Sep 4, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 4, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 5, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Aug 5, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 5, 2024
Protect each resident from the wrongful use of the resident's belongings or money.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 4, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Sep 4, 2024
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Sep 4, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 4, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Sep 4, 2024
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 4, 2024
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 5, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Aug 5, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Aug 5, 2024
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category: Resident Rights Deficiencies
Corrected: Aug 5, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 9, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Apr 9, 2023
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Category: Resident Rights Deficiencies
Corrected: Apr 9, 2023
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 9, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 9, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Apr 9, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Jun 23, 2021
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 22, 2021
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jun 22, 2021
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 22, 2021
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 22, 2021
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 22, 2021
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 22, 2021
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 22, 2021
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Jun 22, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 6.3% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 8.6% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.2% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.6% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 72.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 32.9% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 4.6% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 12.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 89.7% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 45.8% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 9.0% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 33.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 12.1% | Yes |
Penalty History
| Date | Type | Amount |
|---|---|---|
| Jun 6, 2024 | Payment Denial | - |
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Frequently Asked Questions
What is the overall CMS rating for Lilac Manor Rehabilitation and Nursing Center?
What are the staffing levels at Lilac Manor Rehabilitation and Nursing Center?
How many beds does Lilac Manor Rehabilitation and Nursing Center have?
Does Lilac Manor Rehabilitation and Nursing Center have any deficiencies on record?
Has Lilac Manor Rehabilitation and Nursing Center received any fines or penalties?
Who owns Lilac Manor Rehabilitation and Nursing Center?
When was Lilac Manor Rehabilitation and Nursing Center last inspected?
What quality measures are tracked for Lilac Manor Rehabilitation and Nursing Center?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.