Lilac Manor Rehab: Stroke Patient Left Uninformed on Blood Clot Drug - NY
The patient, identified in inspection records only as Resident 1, had been admitted following a diagnosis of acute ischemic stroke, a condition in which a sudden blockage of blood flow to the brain causes brain cells to die. Lovenox, an injectable blood thinner, is commonly used following strokes to reduce the risk of further clotting. At some point during the resident's stay, the injections were discontinued.
The family didn't know.
When a representative for Resident 1 raised the question, they told the provider they weren't sure whether the injections were even happening at the skilled nursing facility. That uncertainty was the first signal that something had gone wrong in the communication between the facility and the people responsible for the resident's care decisions.
Federal inspectors documented the lapse during a complaint investigation completed on August 20, 2025.
During a phone interview on August 18, the facility's Medical Director said they had not been involved with Resident 1's care at the time the medication was discontinued. Then came the statement that sat at the center of the violation: the provider, the Medical Director said, should have notified the resident's representative about the discontinuation of the Lovenox.
Should have. Didn't.
The inspection cited the facility under New York State regulation 10 NYCRR 415.3, which governs resident rights and the responsibilities facilities carry toward the people, and families, in their care. The level of harm was recorded as minimal harm or potential for actual harm, and the citation was noted as affecting few residents.
What the records don't show is how long the representative went without knowing. They don't show when the Lovenox was stopped, who made that decision, or whether any documentation of a notification attempt exists somewhere in the chart. What the records do show is that when the representative asked, they didn't have an answer, and that the Medical Director, when reached by phone two days before the inspection closed, placed the responsibility squarely on the provider while confirming he had been outside the loop entirely.
A stroke patient's family, trying to track whether a blood thinner is being administered, is not asking an unreasonable question. Lovenox isn't a medication whose discontinuation goes unnoticed in a chart review. It requires a prescription, it requires nursing staff to administer it, and stopping it is a clinical decision that carries consequences. The representative's uncertainty suggests no one had a conversation with them at the point the decision was made.
The Medical Director's own words framed the failure plainly. He wasn't involved. The provider should have notified the family. Two sentences, and both of them describe something that didn't happen.
Lilac Manor Rehabilitation and Nursing Center is located in Rochester, New York. The complaint inspection that produced this citation was completed in August 2025. The facility received a single deficiency citation from this review, at the lower end of the harm scale. Regulators noted few residents were affected.
For the representative of Resident 1, the question they had been asking, whether their family member was even getting the medication, was answered only after a complaint had been filed and investigators had made calls. By then, the injections had already been stopped. The conversation that should have happened before any of that, the one where a provider picks up the phone and says the Lovenox is being discontinued and here is why, never came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lilac Manor Rehabilitation and Nursing Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 15, 2026 · Our methodology
Lilac Manor Rehabilitation and Nursing Center in Rochester, NY was cited for violations during a health inspection on August 20, 2025.
Lovenox, an injectable blood thinner, is commonly used following strokes to reduce the risk of further clotting.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.