Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Lilac Manor Rehabilitation and Nursing Center
Rochester, NY · 200 certified beds · Last Life Safety survey June 6, 2024
CMS Certification Number 335488 · first certified July 1976
Ownership
Independently operated (no chain recorded by CMS) · For profit - Individual
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
5 citations — more than 10% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
When is the next survey likely?
Past the typical window (November 2025 to July 2026). Most NY facilities have been surveyed by December 2026. This facility’s last Life Safety survey was June 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
5 of the 5 citations on file are Emergency Preparedness E-tags — every citation here is about the program, not the building. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 5 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0908 Keep all essential equipment working safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 5 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 23, 2021 | 0 |
| February 8, 2023 | 0 |
| June 6, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2024-06-06 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2024-06-06 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-06-06 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2024-06-06 |
| E-0042 | Meet the requirements of an integrated health system. | 1 | 2024-06-06 |
What the citations cover
- Emergency Preparedness Deficiencies 5
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 5 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 6, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 5, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (August 5, 2024) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (August 5, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 5, 2024) |
| E-0042 | Meet the requirements of an integrated health system. | Deficient, Provider has date of correction (August 5, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.