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 16 of 16 citations

  1. 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).

  2. 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).

  3. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

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

    Assess the resident when there is a significant change in condition

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

    Health citation F-0637, 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

    PASARR screening for Mental disorders or Intellectual Disabilities

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

    Health citation F-0645, 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

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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

    Health citation F-0657, 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).

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

    Provide activities to meet all resident's needs.

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

    Health citation F-0679, Quality of Life and Care Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

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

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

    Provide safe and appropriate respiratory care for a resident when needed.

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

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

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

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

    Provide care or services that was trauma informed and/or culturally competent.

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

    Health citation F-0699, Quality of Life and Care Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

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

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

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

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

    Health citation F-0883, Infection Control Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

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

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

    Have policies on smoking.

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

    Health citation F-0926, Environmental Deficiencies. Inspection of May 4, 2023. Found during a standard inspection.

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

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.