Deficiency Index

Lilac Manor Rehabilitation and Nursing Center

Rochester, New York · CCN 335488

33 surveys since 2010. The first finding at harm level was recorded in 2015.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
156
Surveys
33
Harm or worse
5
Immediate jeopardy
1
The record, 2010–2026
’10’15’20’25’26
No harm recordedHarm or worseNot surveyed
Immediate jeopardy1

Findings at the most serious level CMS records.

Beyond CMS’s monthly file28/33

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
200
Ownership
For profit - Individual
Chain
Independent
County
Monroe
Medicare-certified since
1976

CMS ratings

Overall
1
Health inspection
1
Staffing
3
Quality measures
3

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded more weighted findings than most of its peer group.

Weighted by harm level, against 259 for-profit facilities with 128 or more beds in New York.

Last survey on record

May 15, 2026

178 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.493.37
Registered-nurse hours per resident day0.61—
Annual nurse turnover70.0%33.3%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

Payment denials
1

Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD2259.5%E924.3%F—
No harm, potential for minimalA—B616.2%C—
CMS’s current file: 37 of the 156 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F5803×

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

  • F5842×

    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.

  • F6102×

    Respond appropriately to all alleged violations.

  • F6772×

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

  • F6952×

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

In the surveyor’s words

From the most serious findings on record at Lilac Manor Rehabilitation and Nursing Center, in the surveyor’s own words.

  • Immediate jeopardy, patternF578Sep 18, 2021

    Based on observation, interviews, and record reviews conducted during an Abbreviated Survey (#NY 267) completed on [DATE], the facility failed to ensure that residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive for 14 (Residents #1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13,#14, and #15) of 97 residents reviewed. Specifically, Resident #1 was admitted [DATE] and had Full Code wishes via a Medical Orders for Life Sustaining Treatment (MOLST). The resident changed their wishes to (Do Not Resuscitate) DNR (via a new MOLST) on [DATE], was hospitalized on [DATE] and returned to the facility on [DATE] maintaining their DNR wishes. […]

  • No harm, potential for more than minimal, patternF677Aug 13, 2026

    Based on observations, interviews, and record review conducted during the Recertification Survey, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene and grooming for three of seven residents reviewed (Residents #40, #53, and #120). Specifically, Residents #40 and #53 required staff assistance with hand hygiene and nail care and were repeatedly observed with dark debris under their fingernails, including while eating meals, without staff providing needed hand hygiene. […]

  • No harm, potential for more than minimal, patternF584May 15, 2026

    Based on observations, interviews, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, for two (2) of three (3) resident rooms (Rooms #215 and #524). Specifically, there were multiple ceiling tiles with stains, cracks, and bowing (drooping or curving downward) observed in room [ROOM NUMBER] (Resident #4's room) and multiple ceiling tiles with stains in room [ROOM NUMBER]. The findings include:The facility's Maintenance Service policy dated April 2025 included the Maintenance Department was responsible for maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines; and maintaining the building in good repair.During an observation on… […]

  • No harm, potential for more than minimal, patternF925May 15, 2026

    Based on observations, interviews, and record review, the facility failed to ensure an effective pest control program for three (3) (Second Floor, Third Floor, and Fifth Floor) of six (6) resident use floors. Specifically, mouse droppings and pest harborage (any condition, location, or physical environment that provides shelter, protection, or breeding grounds for pests) areas were observed on the Second, Third, and Fifth floors, and Resident #1 stated they had seen a mouse in their room.The findings include:The facility's Pest Control Policy, dated April 2025, included the facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents.During an observation on 05/13/2026 at 3:31 PM, there were mouse droppings on the floor on both sides… […]

  • No harm, potential for more than minimal, patternF584Jun 6, 2024

    Based on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigations (NY00327022, NY00323935, NY00343607) it was determined that for five (1st, 2nd, 3rd, 4th, and 5th floors) of five occupied resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, hot water was not maintained above 90 degrees Fahrenheit ( F), floors, walls, and ceilings were dirty and/or in disrepair, bathrooms and shower rooms were dirty and in disrepair, ventilation exhaust units in bathrooms, showers, and soiled utility rooms were not functioning resulting in foul odors, ice machines were dirty, ready stand lifts were dirty,… […]

Read 25 findings in full →The most serious and the most recent: 25 of 156 on record.

Every survey on record

FindingsAt actual harm or above

  • Aug 13, 2026Complaint1 finding
  • May 15, 2026Complaint2 findings
  • Aug 20, 2025Complaint1 finding
  • Jun 6, 2024Standard20 findings
  • Feb 8, 2023Standard and complaint6 findings
  • Nov 22, 2022Complaint1 finding
  • Mar 17, 2022Complaint2 findings
  • Sep 18, 2021Complaint1 finding · 1 harm
Show the 25 earlier surveys
  • Apr 23, 2021Standard9 findings
  • Dec 29, 2020Complaint1 finding
  • Nov 21, 2020Infection control1 finding
  • Aug 22, 2019Standard21 findings · 2 harm
  • Aug 2, 2019Complaint3 findings
  • Mar 20, 2019Complaint1 finding
  • Dec 27, 2018Complaint2 findings
  • May 21, 2018Standard21 findings
  • Mar 1, 2017Standard8 findings
  • Jul 14, 2016Complaint4 findings
  • Apr 28, 2016Complaint2 findings · 1 harm
  • Jan 20, 2016Standard and complaint9 findings
  • Sep 18, 2015Complaint1 finding · 1 harm
  • Apr 22, 2015Complaint1 finding
  • Dec 12, 2014Standard3 findings
  • Aug 1, 2014Complaint2 findings
  • Jul 3, 2014Complaint1 finding
  • Dec 23, 2013—2 findings
  • Oct 30, 2013—5 findings
  • Aug 15, 2013—1 finding
  • Dec 20, 2012—1 finding
  • Sep 5, 2012—8 findings
  • Aug 29, 2011—13 findings
  • Apr 29, 2011—1 finding
  • Sep 24, 2010—1 finding

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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