Inspection Reports for
Lilac Manor Rehabilitation and Nursing Center
3 Upton Park, Rochester, NY, 14607
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Inspection Report — Aug 20, 2025
Complaint Investigation State
Date: Aug 20, 2025
Visit Reason
State-compiled facility profile showing 14 inspections from 2022 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 166 complaints about this facility; 24 led to on-site inspections. Complaint surveys from 2022 to 2025 resulted in multiple citations.
Findings
Across 14 inspections, 9 resulted in citations totaling 113 deficiencies primarily related to standard health and life safety code issues. The facility had 166 complaints with 24 on-site inspections and 6 enforcement actions totaling $34,000 in fines.
Citations (60)
Standard Health Citation — quality of care: Notify Of Changes (injury/decline/room, Etc.) deficiency noted in 2025 complaint survey.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Administration deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Baseline Care Plan deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Behavioral Health Services deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Essential Equipment, Safe Operating Condition deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Free From Misappropriation/exploitation deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: License/comply W/ Fed/state/locl Law/prof Std deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Medicaid/medicare Coverage/liability Notice deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Notice Requirements Before Transfer/discharge deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Pain Management deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Posted Nurse Staffing Information deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Request/refuse/dscntnue Trmnt;formlte Adv Dir deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Requirements Before Submitting A Request For deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notif deficiency noted in 2024 certification/complaint survey (two separate findings).
Standard Health Citation — quality of care: Right To Survey Results/advocate Agency Info deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Standards Of Construction For New Nh deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Treatment/devices To Maintain Hearing/vision deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Aisle, Corridor, Or Ramp Width deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Building Construction Type And Height deficiency noted in 2024 certification/complaint survey and 2023 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Cooking Facilities deficiency noted in 2024 and 2023 certification/complaint surveys.
Life Safety Code Citation — NFPA requirements: Develop Ep Plan, Review And Update Annually deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Development Of Ep Policies And Procedures deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenanc deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste deficiency noted in 2024 certification/complaint survey (multiple findings).
Life Safety Code Citation — NFPA requirements: Elevators deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Emergency Lighting deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Ep Testing Requirements deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Fire Drills deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storag deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Hvac deficiency noted in 2024 and 2023 certification/complaint surveys.
Life Safety Code Citation — NFPA requirements: Integrated Ep Program deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Ltc And Icf/iid Sharing Plan With Patients deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiency noted in 2024 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie deficiency noted in 2024 certification/complaint survey.
Standard Health Citation — quality of care: Accounting And Records Of Personal Funds deficiency noted in 2023 certification/complaint survey.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents deficiency noted in 2023 certification/complaint survey.
Standard Health Citation — quality of care: Care Plan Timing And Revision deficiency noted in 2023 certification/complaint survey.
Standard Health Citation — quality of care: Drug Regimen Review, Report Irregular, Act On deficiency noted in 2023 certification/complaint survey.
Standard Health Citation — quality of care: Notify Of Changes (injury/decline/room, Etc.) deficiency noted in 2023 certification/complaint survey.
Standard Health Citation — quality of care: Posted Nurse Staffing Information deficiency noted in 2023 certification/complaint survey.
Standard Health Citation — quality of care: Standards Of Construction For New Nh deficiency noted in 2023 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Building Construction Type And Height deficiency noted in 2023 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Cooking Facilities deficiency noted in 2023 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste deficiency noted in 2023 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance deficiency noted in 2023 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Hvac deficiency noted in 2023 certification/complaint survey.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiency noted in 2023 certification/complaint survey.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation deficiency noted in 2022 complaint survey.
Standard Health Citation — quality of care: Reporting - National Health Safety Network deficiency noted in multiple 2022 COVID19 surveys.
Report Facts
Inspections on page: 14
Total violations/deficiencies cited: 113
Inspections with violations: 9
Inspections without violations: 5
Total complaints: 166
On-site complaint inspections: 24
Citations from complaints: 37
Enforcement actions: 6
Total fines: 34000
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