All citations for Sixteen Acres Health and Rehabilitation Center LLC

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Sixteen Acres Health and Rehabilitation Center LLC

Last standard health inspection on record

December 9, 2025

Showing 1 to 25 of 35 citations

  1. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  2. No harm, with potential for more than minimal harm

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    Widespread (many residents). CMS level F.

    Health citation F-0636, Resident Assessment and Care Planning Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 7, 2023).

  3. No harm, with potential for more than minimal harm

    Assure that each resident’s assessment is updated at least once every 3 months.

    Widespread (many residents). CMS level F.

    Health citation F-0638, Resident Assessment and Care Planning Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 7, 2023).

  4. No harm, with potential for more than minimal harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Widespread (many residents). CMS level F.

    Health citation F-0804, Nutrition and Dietary Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 7, 2023).

  5. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2026).

  6. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2026).

  7. No harm, with potential for more than minimal harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0623, Resident Rights Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 7, 2023).

  8. No harm, with potential for more than minimal harm

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0625, Resident Rights Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 7, 2023).

  9. No harm, with potential for more than minimal harm

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0640, Resident Assessment and Care Planning Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 7, 2023).

  10. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 7, 2023).

  11. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 16, 2023).

  12. No harm, with potential for more than minimal harm

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0676, Quality of Life and Care Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2026).

  13. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2026).

  14. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2026).

  15. No harm, with potential for more than minimal harm

    Ensure 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2026).

  16. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 20, 2026).

  17. No harm, with potential for more than minimal harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of December 9, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2025).

  18. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 5, 2024).

  19. No harm, with potential for more than minimal harm

    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0622, Resident Rights Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 5, 2024).

  20. No harm, with potential for more than minimal harm

    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0700, Quality of Life and Care Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 5, 2024).

  21. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 5, 2024).

  22. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2024).

  23. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2024).

  24. No harm, with potential for more than minimal harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0355, Smoke Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2024).

  25. No harm, with potential for more than minimal harm

    Provide a written emergency evacuation plan.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of August 22, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 2, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.