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TheVardellReport
Lilac Manor Rehabilitation and Nursing Center
Skilled nursing facility and nursing facility
3 Upton Park
Rochester, NY 14607
Report
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The Vardell Report.Lilac Manor Rehabilitation and Nursing Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Rochester, NY
- Record Period
- 2021–2026
- Source Documents
- 8
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 6 inspections from April 2021 to August 2026, state surveyors documented 38 findings at Lilac Manor Rehabilitation and Nursing Center; 37 have a recorded correction and 1 awaits one; CMS lists 1 enforcement action in the window.
- Inspections
- 6
- 2021–2026, complaint and standard
- Findings
- 38
- Deficiencies cited by state inspectors
- Corrected
- 37
- Of 38 findings, with a recorded correction date
- Penalties
- 1
- 1 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2021 | 1 | 9 | 0 |
| 2022 | 0 | 0 | 0 |
| 2023 | 1 | 5 | 0 |
| 2024 | 1 | 20 | 0 |
| 2025 | 1 | 1 | 0 |
| 2026 | 2 | 3 | 0 |
What the Record Shows
- 37 of 38 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: denial of payment imposed June 6, 2024, ended November 18, 2024.
- 4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, June 6, 2024, recorded 20 findings (most serious: Level E).
What to Ask About
- Telling Families About Changes, Cited in Three Inspections
- A Clean, Homelike Setting, Cited in Two Inspections
- Investigating Alleged Violations, Cited in Two Inspections
- Respiratory Care, Cited in Two Inspections
- Post nurse staffing information every day, Cited in Two Inspections
- Citation F756, Cited in Two Inspections
- Help With Daily Living, No Recorded Correction
Report at a Glance
- Facility
- Lilac Manor Rehabilitation and Nursing Center
- Address
- 3 Upton Park, Rochester, NY 14607
- CMS Certification Number
- 335488
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 200
- Ownership
- For profit - Individual
- Record Window
- April 23, 2021 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
2 findings
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Jul 10, 2026
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Jul 10, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Oct 15, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
20 findings
The same visit included a complaint investigation.
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Sep 4, 2024
- F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Aug 5, 2024
- F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Sep 4, 2024
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Sep 4, 2024
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Sep 4, 2024
- F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Sep 4, 2024
- F578Honor 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.Level DNo actual harm, potential for moreCorrected Aug 5, 2024
- F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Sep 4, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Aug 5, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Sep 4, 2024
- F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Aug 5, 2024
- F688Provide 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.Level DNo actual harm, potential for moreCorrected Aug 5, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 5, 2024
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 5, 2024
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Sep 4, 2024
- F836Ensure 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.Level DNo actual harm, potential for moreCorrected Aug 5, 2024
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level BPotential for minimal harmCorrected Aug 5, 2024
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level BPotential for minimal harmCorrected Aug 5, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel BPotential for minimal harmCorrected Aug 5, 2024
- F732Post nurse staffing information every day.Level BPotential for minimal harmCorrected Sep 4, 2024
Enforcement Action
Denial of payment imposed June 6, 2024. Status: Closed, November 18, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 6, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
5 findings
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 9, 2023
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 9, 2023
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Apr 9, 2023
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level BPotential for minimal harmCorrected Apr 9, 2023
- F732Post nurse staffing information every day.Level BPotential for minimal harmCorrected Apr 9, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2021
Standard health inspection
9 findings
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 22, 2021
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jun 22, 2021
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 22, 2021
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jun 22, 2021
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 22, 2021
- F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jun 22, 2021
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 22, 2021
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jun 22, 2021
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jun 23, 2021
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Telling Families About Changes, Cited in Three Inspections
Inspectors cited F580 in April 2021, February 2023 and August 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212324252626F580 across all 6 inspections, oldest to newest - 2
A Clean, Homelike Setting, Cited in Two Inspections
Inspectors cited F584 in June 2024 and May 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212324252626F584 across all 6 inspections, oldest to newest - 3
Investigating Alleged Violations, Cited in Two Inspections
Inspectors cited F610 in April 2021 and June 2024. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212324252626F610 across all 6 inspections, oldest to newest - 4
Respiratory Care, Cited in Two Inspections
Inspectors cited F695 in April 2021 and June 2024. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212324252626F695 across all 6 inspections, oldest to newest - 5
Post nurse staffing information every day, Cited in Two Inspections
Inspectors cited F732 in February 2023 and June 2024. The agency describes it this way: Post nurse staffing information every day. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212324252626F732 across all 6 inspections, oldest to newest - 6
Citation F756, Cited in Two Inspections
Inspectors cited F756 in April 2021 and February 2023. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212324252626F756 across all 6 inspections, oldest to newest - 7
Help With Daily Living, No Recorded Correction
F677 was cited in April 2021, June 2024 and August 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
212324252626F677 across all 6 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in three inspections, most seriously at level D.
- 02
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in two inspections, most seriously at level E.
- 03
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in two inspections, most seriously at level E.
- 04
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in two inspections, most seriously at level D.
- 05
What changed after F732 was cited, and how do you check it now?
Post nurse staffing information every day: cited in two inspections, most seriously at level B.
- 06
What changed after F756 was cited, and how do you check it now?
Citation F756: cited in two inspections, most seriously at level D.
- 07
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in three inspections, most seriously at level E. The August 13, 2026 citation has no recorded correction date.
- 08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 09
What led to the 2024 denial of payment, and what would you want a family to know about it?
Denial of payment was imposed June 6, 2024; it ended November 18, 2024.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the New York state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
New York state survey agency
Inspection Apr 23, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
New York state survey agency
Inspection Feb 8, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
New York state survey agency
Inspection Jun 6, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
New York state survey agency
Inspection Aug 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
New York state survey agency
Inspection May 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
New York state survey agency
Inspection Aug 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 335488
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowApril 23, 2021 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before April 2021 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.