Lilac Manor Rehabilitation and Nursing Center

Inspectors wroteBased 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].

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record review conducted during the Abbreviated Survey (Complaint ID: NY00357848/520132) from 08/18/2025 to 08/20/2025, for one (1) (Resident #1) of five (5) residents reviewed, the facility did not immediately notify the resident representative when there was a need to alter treatment significantly. Specifically, Resident #1 was prescribed Lovenox (a medication used to treat and prevent blood clots) injections. Following several refusals of the medication, it was discontinued by a provider, and the resident representative was not notified. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey and Complaint Investigations (NY00337587, NY00324938, NY00321613, NY00323935, NY00317625, NY00328756) for six of six residents reviewed, the facility could not provide evidence that allegations of resident abuse and injuries of unknown origin were thoroughly investigated. Specifically for Resident #22 there was no evidence that an allegation of staff abuse had been investigated. For Residents #44, #68 and #100 there was no evidence that allegations of resident-to-resident abuse had been investigated. For Residents #87 and #371 there was no evidence that the facility investigated injuries of unknown origin. This is evidenced by but not limited to the following: 1. Resident #371 had diagnoses that included a history of falls, adult failure to thrive, and visual hallucinations. [...]

Inspectors wroteBased on interviews, and record review conducted during the Recertification Survey and Complaint Investigation (NY00318393), it was determined that for 4 of 10 residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was no documented evidence that Resident #37 had received multiple prescribed medications on multiple days, that Resident #42 received the correct dose of narcotic pain medication on several days, that Resident #52 received the correct doses of narcotic pain medication on several days, and that Resident #100 had received the full ordered course of an antibiotic as ordered. This is evidenced by the following: [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey, the facility did not provide for safe and secure storage of medications and ensure that medications were labeled in accordance with currently accepted professional standards for two (3rd and 4th floor resident units) of two medication rooms and two (3rd and 4th floor) of four medication carts and one clean utility room (3rd floor) reviewed Specifically, medications were observed stored in an unlocked clean utility room, resident specific medications were not labeled, and medication carts contained several unidentified loose pills, and were unclean. This is evidenced by but not limited to the following: The facility policy, Storage of Medications, dated [DATE] documented that drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, the facility did not ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; did not ensure all allegations of resident abuse and injuries with unknown origin were thoroughly investigated; did not ensure that residents who required assistance with activities of daily living received the necessary services to maintain good grooming and personal hygiene; did not ensure that each resident received necessary behavioral health care and services; [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for five (1st, 2nd, 3rd, 4th, and 5th floors) of five resident use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, an oxygen concentrator, and ventilation systems were not maintained in working order.

Inspectors wroteBased on interviews, and record reviews conducted during the Recertification Survey and Complaint Investigation (NY00318393) completed on [DATE], for four of five residents reviewed for advanced directives, the facility did not ensure that there was an organized system to ensure that resident wishes regarding Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR - do not initiate Cardiopulmonary Resuscitation in the event of acute cardiac or respiatory event) were followed. Specifically, Residents #22, #29, and #59 had discrepancies in their code status as identified on facility forms. Additionally, Resident #115 gave verbal consent on their Medical Orders for Life Sustaining Treatment (known as a MOLST) for Full Code (initiate Cardiopulmonary Resuscitation for acute cardiac and/or respiratory event) that was not signed by two witnesses. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey and Complaint Investigation (NY00326620), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for two (Residents #28, #57) of four residents reviewed for missing property and for three (Residents #59, #99, and #108) residents interviewed during Resident Council. Specifically, the residents reported missing money, clothing, and personal items and the facility was unable to provide documentation that the missing property complaints had been investigated and/or any resolutions offered for the missing property. This is evidenced by the following: The facility policy Personal Property with a revised date of August 2022, documented the facility promptly investigates any complaints of misappropriation or mistreatment of resident property. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey and Complaint Investigation (NY00327022), for three (Residents #90, #116, #371) of four residents reviewed the facility did not ensure that notification of a discharge/transfer was provided to the resident and/or the resident's representative in writing, and in a language and manner they understood, as soon as possible when an immediate discharge/transfer was required by the resident's urgent medical needs. Additionally, the facility did not ensure a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey and Complaint Investigations (NY318393, NY00323935, NY00328756, and NY00343607) for three (Residents #52, #76, #87) of nine residents reviewed the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #52 was not provided with the assistance to obtain a haircut, Resident #76 was observed with uncut nails and unshaven facial hair and Resident #87 had oily and unwashed hair. This is evidenced by the following: [...]

Inspectors wroteBased on observation, interview and record review conducted during a Recertification Survey the facility did not ensure that proper treatment to maintain hearing abilities was provided for one (Resident #51) of one resident reviewed for hearing. Specifically, Resident #51 did not have their ears flushed per Physician orders. This is evidenced by: The facility policy, Activities of Daily Living, dated May 2018, documented residents will be provided with care, treatment, and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing activities of daily living are unavoidable. Resident #51 had diagnoses including chronic obstructive pulmonary disease, diabetes, and hypertension. [...]

Inspectors wroteBased on Observations, interviews and record review conducted during a Recertification Survey, the facility did not ensure that residents with limited range of motion received appropriate treatment, equipment, and services to increase range of motion and/or to prevent further decrease in range of motion for two (Resident #37 and #90) of two residents reviewed. Specifically, the residents were observed on multiple occasions not wearing their therapy recommended hand splints. This is evidenced by the following: 1. Resident #37 has diagnoses including dementia, malnutrition, and contractures (permanent tightening of the muscles and tendons causing joint stiffness and pain and loss of function). [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigations (NY00315983, NY00318393), for one (Resident #42) of two residents reviewed for respiratory care, the facility did not ensure residents who needed respiratory care were provided such care consistent with professional standards of practice. Specifically, Resident #42 did not have a physician order in place for oxygen use, did not have a person-centered comprehensive care plan for oxygen, and was not provided a clean well-functioning oxygen concentrator. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigation (NY00318393) it was determined that for one (Resident #52) of one resident reviewed, the facility did ensure the resident's pain was managed to the extent possible in accordance with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences. Specifically, Resident #52's pain medication was not administered as ordered on multiple occasions without Physician notification and the resident did not have a comprehensive care plan for chronic pain that included measurable goals and person centered interventions. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey the facility did not ensure the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #52) of one resident reviewed. Specifically, Resident #52 did not receive medication changes as recommended, did not have a comprehensive care plan that included an individualized person-centered approach to address their behavioral health needs, and did not receive consistent psychiatric services. This is evidenced by the following: [...]

Inspectors wroteBased on observations, record review, and interview conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances.

Inspectors wroteBased on observations and interviews and record review conducted during the Recertification Survey, it was determined the facility did not ensure the results of the most recent New York State Department of Health inspection survey conducted by Federal or State surveyors was available for residents, family members, and legal representatives and was posted in a place that was readily accessible to all residents and visitors. Specifically, the most recent survey results, including the plan of correction, was not available without individuals having to ask for them, the sign stating that they were available if requested was not easily readable for wheelchair bound residents or visitors and when asked the Receptionist was unable to provide the prior three years of Recertification and Abbreviated (complaint investigations) surveys. This is evidenced by the following: [...]

Inspectors wroteBased on interview and record review conducted during the Recertification Survey for two (Residents #12 and #534) of three residents reviewed, the facility did not ensure that the appropriate appeal notices were provided to Medicare beneficiaries prior to the termination of their Medicare benefits. Specifically, the residents/resident representatives were not provided with a Notice of Medicare Noncoverage letter informing them of their appeal rights following the termination of their Medicare benefits. This is evidenced by the following: Resident #12 was admitted to the facility under Medicare Part A services and was termed from Medicare A benefits effective 12/28/23. The resident remained in the facility for long term care with services not covered under Medicare. [...]

Inspectors wroteBased on interviews, and record review conducted during the Recertification Survey, for four (Residents #57, #73, #105, and #519) of 13 residents reviewed the facility did not ensure a baseline care plan had been completed within 48 hours of a resident's admission and that a summary of the baseline care plan had been provided to the resident and/or their representative. Specifically, for Resident #57, the facility could not provide documented evidence that a baseline care plan had been completed within 48 hours of the resident's admission. For Residents #73, #105, and #519, the facility could not provide evidence that a summary of the baseline care plan had been provided to the resident and/or their representative. This included, but was not limited to, the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, the facility did not ensure the nurse staffing information was posted daily and included the required information. Specifically, the nurse staffing information did not consistently include the accurate number and total hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, the accurate daily resident census (the number of residents currently residing in the facility), and did not include any staffing changes (to include any changes in nurse staffing throughout the day) as per regulations. This is evidenced by the following: During observations on 5/28/24 at 8:32 AM, 5/29/24 at 3:40 PM, 5/31/24 at 9:00 AM and again at 1:43 PM, and 6/4/24 at 10:19 AM the facility's nurse staffing information posted did not document a resident census. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey completed on 2/8/23, it was determined that for one (Resident #109) of one resident reviewed for notification of changes, the facility did not notify the resident's medical team of a change in the resident's physical, mental or psychosocial status. Specifically, Resident #109 was noted to have a skin condition which was not reported to the medical team in a timely manner. This is evidenced by the following. Resident #109 had diagnoses that included Non-Hodgkin's Lymphoma ( a type of blood cancer), anxiety disorder and depression. The Minimum Data Set assessment dated [DATE], documented that Resident #109 was severely impaired cognitively and required extensive assist and total dependance on staff for personal hygiene and bathing respecfully. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey completed on 2/8/23, it was determined that for one (Resident #377) of two residents reviewed for pressure ulcers, the facility did not revise the resident's care plan to reflect the resident's current needs. Specifically, Resident #377's Comprehensive Care Plan (CCP) was not revised to include the presence of multiple wounds, goals and related interventions. This is evidenced by the following: Resident #377 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease (dependent on hemodialysis), diabetes, and heart failure. The Minimum Data Set assessment dated [DATE], documented that Resident #377 was cognitively intact, and did not have any pressure ulcers. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey completed on 2/8/23, it was determined that for three (Resident #29, #71, and #80) of five residents reviewed for unnecessary medications, the facility did not ensure that the Drug Regimen Review (DRR) that was completed by the pharmacist was reviewed by the physician for irregularities/recommendations and action taken if any and/or a rationale if no action taken. Specifically, the pharmacist made recommendations for each of the identified residents during the period of August 2022 through December 2022 and the facility was unable to provide evidence that the recommendations had been addressed by the physician in a timely manner. This is evidenced by the following: [...]

Inspectors wroteBased on interviews and record reviews during the Recertification Survey and complaint investigation (NY00302137), completed on 2/8/23, it was determined for three (Residents #14, #39 and #61) of four residents reviewed for personal funds, the facility did not ensure that individual financial records were provided to the residents through quarterly statements. Specifically, the residents were not provided with their personal fund statements on a quarterly basis per their preference or on request. This is evidenced by the following: 1. Resident #39 was admitted on [DATE] with diagnoses including dementia and vision and hearing loss. The Minimum Data Set (MDS) assessment dated [DATE] included the resident had moderate impairment of cognitive function. [...]

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey completed on 2/8/23, it was determined that the facility did not ensure that the daily posting of licensed and unlicensed nursing staff on duty was posted with the required information. Specifically, the staffing information did not include the required hours or current facility census. This was evidenced by the following: During observations on 2/1/23 at 9:59 a.m., 2/2/23 at 8:34 a.m., and 2/3/23 at 11:12 a.m., the nurse staffing sheets reflected the number of licensed and unlicensed staff on duty for the day shift 7:00 a.m.-3:00 p.m. The number of hours scheduled for nursing staff and the current facility census (how many residents the nurses were caring for) were not included on the posted nurse staffing sheets per the regulations. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 4/23/21, the facility failed to maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of COVID-19 for 1 (5th floor resident care unit) of 4 units reviewed. Specifically, staff were not wearing required Personal Protective Equipment (PPE) while providing care to residents on transmission-based precautions (TBP). This is evidenced by but not limited to the following: [...]

Inspectors wroteBased on interview and record review conducted during the Recertification Survey and complaint investigation (# NY00272244) it was determined for 1 (# 302) of 2 residents reviewed for hospitalization, the facility did not notify the legal representative of a change in condition or transfer to the hospital. This is evidenced by the following: The facility policy Transfer and Discharge from the Facility, dated June 2019 included the resident and representative will receive timely notification of any discharge from the facility and in an emergency as soon as practicable. Resident #302 was admitted [DATE] with diagnoses of bacteremia (infection of the bloodstream), methicillin resistant staphylococcus aureus infection, and alcoholic cirrhosis of the liver. The resident was discharged to the hospital on 2/26/21. Review of the interdisciplinary progress notes dated 2/26/21 are as follows: a. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey it was determined that for one (Resident #37) of two residents reviewed the facility did not investigate injuries of unknown origin in order to rule out abuse, mistreatment, or neglect. The issue involved the lack of an investigation for multiple bruises. This was evidenced by the following: Review of the facility policy titled Abuse (alleged) Reporting, dated 6/27/04, included an injury is classified as unknown when the source of the injury was not observed by any person or the source of the injury cannot be explained and the injury is suspicious because of the extent of the injury. Resident # 37 was admitted to the facility on [DATE] with diagnoses that included bipolar disease, intellectual disability, and drug induced dyskinesia (involuntary erratic movements). [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 2 (Residents # 41 and #74) of 25 residents reviewed , the facility did not develop and implement a Comprehensive Care Plan (CCP) that included measurable objectives to meet the resident's medical, nursing and psychosocial needs that include the resident's goals, desired outcomes and preferences to attain or maintain the resident's highest practicable well-being. Specifically, there was a lack of care planning to address the use of an anti-depressive medication and an anti-coagulant medication for Resident #41 and lack of care planning to address the use of an anti-psychotic medication for Resident #74. This is evidenced by the following: 1. Resident #41 had diagnoses that included atrial fibrillation (irregular heart rate), anxiety, and repeated falls. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey and complaint investigations (#NY00272865, #NY00260255, #NY00260976, #NY00264416, #NY00271424, #NY00268463, #NY00268822, #NY00272312) it was determined that for two of nine residents reviewed the facility did not provide the residents who were unable to carry out activities of daily living (ADLs) the necessary services to maintain grooming, personal care and oral hygiene. Specifically, Resident #26 lacked shaving and mouth and nail care and Resident #58 lacked hair care. This is evidenced by the following: The facility policy ADL Care Guidelines, dated March 2020, included that caregivers will review resident nursing care instructions at the beginning of each shift to assure that care is given according to the individual's plan of care. [...]

Inspectors wroteBased on observation, interviews and record review conducted during a Recertification Survey it was determined that for three (Residents #32, #37 and #41) of four residents reviewed, the facility did not provide an ongoing activity program based on the comprehensive assessment and resident care plans to meet the interest of and support the physical, mental and psychosocial well-being of each resident. Specifically, residents were not consistently provided with activities of their choice. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined for 2 of 2 residents reviewed, the facility did not ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, Resident #10 was not receiving oxygen according to the physician order and the oxygen tubing was dirty and unlabeled. Resident #43 was not receiving oxygen according to the physician order, there was missing documentation for oxygen administration, and oxygen tubing had not been changed. This is evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey, it was determined that for one (Resident # 10) of five residents reviewed, the facility did not ensure that pharmacy recommendations were addressed or acted upon in a timely manner. Specifically, Resident #10 pharmacy recommendations related to a gradual dose reduction (GDR) of a psychotropic medication and irregularities noted by the pharmacist were not addressed. This is evidenced by the following: The facility policy, Psychotropic Medication Monitoring, dated March 2020, revealed that the Medication Regimen Review (MRR) findings will reflect information to assist the medical provider in ordering the most effective medication regimen for the resident. The Nurse Manager or designee will complete the review in the resident's electronic medical record. [...]

Inspectors wroteBased on observation and interview conducted during the Recertification Survey, it was determined that for one of one main lobby, the facility did not provide a safe environment for residents, staff, and the public. Specifically, a heating surface exceeded 125 degrees (°) Fahrenheit (F) and was not protected from accidental contact.