Sixteen Acres Health And Rehabilitation Center LLC

Inspection history (28)

• December 9, 2025 · D

  Citation F0677

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0677 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide care and assistance to perform activities of daily living for any resident who is unable. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• December 9, 2025 · B

  Citation F0644

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0644 (CMS scope/severity B: pattern, no actual harm, potential for minimal harm) for Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• December 9, 2025 · E

  Citation F0812

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0812 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• December 9, 2025 · D

  Citation F0676

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0676 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• December 9, 2025 · D

  Citation F0761

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0761 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• December 9, 2025 · D

  Citation F0755

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0755 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• December 9, 2025 · E

  Citation F0880

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0880 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Provide and implement an infection prevention and control program. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• December 9, 2025 · D

  Citation F0842

  Federal surveyors cited this nursing home on 2025-12-09 under CMS tag F0842 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. The deficiency was recorded as corrected on 2026-01-20. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-12-09.GOV

• August 22, 2024 · D

  Citation F0622

  Federal surveyors cited this nursing home on 2024-08-22 under CMS tag F0622 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2024-10-05. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-08-22.GOV

• August 22, 2024 · D

  Citation F0842

  Federal surveyors cited this nursing home on 2024-08-22 under CMS tag F0842 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. The deficiency was recorded as corrected on 2024-10-05. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-08-22.GOV

• August 22, 2024 · D

  Citation F0584

  Federal surveyors cited this nursing home on 2024-08-22 under CMS tag F0584 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2024-10-05. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-08-22.GOV

• August 22, 2024 · B

  Citation F0641

  Federal surveyors cited this nursing home on 2024-08-22 under CMS tag F0641 (CMS scope/severity B: pattern, no actual harm, potential for minimal harm) for Ensure each resident receives an accurate assessment. The deficiency was recorded as corrected on 2024-10-05. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-08-22.GOV

• August 22, 2024 · D

  Citation F0700

  Federal surveyors cited this nursing home on 2024-08-22 under CMS tag F0700 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2024-10-05. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-08-22.GOV

• May 4, 2023 · D

  Citation F0883

  Federal surveyors cited this nursing home on 2023-05-04 under CMS tag F0883 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Develop and implement policies and procedures for flu and pneumonia vaccinations. The deficiency was recorded as corrected on 2023-07-07. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-05-04.GOV

• May 4, 2023 · F

  Citation F0636

  Federal surveyors cited this nursing home on 2023-05-04 under CMS tag F0636 (CMS scope/severity F: widespread, no actual harm, potential for more than minimal harm) for Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. The deficiency was recorded as corrected on 2023-07-07. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-05-04.GOV

• May 4, 2023 · D

  Citation F0637

  Federal surveyors cited this nursing home on 2023-05-04 under CMS tag F0637 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Assess the resident when there is a significant change in condition. The deficiency was recorded as corrected on 2023-07-07. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-05-04.GOV

• May 4, 2023 · E

  Citation F0623

  Federal surveyors cited this nursing home on 2023-05-04 under CMS tag F0623 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. The deficiency was recorded as corrected on 2023-07-07. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-05-04.GOV

• May 4, 2023 · D

  Citation F0657

  Federal surveyors cited this nursing home on 2023-05-04 under CMS tag F0657 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. The deficiency was recorded as corrected on 2023-07-07. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-05-04.GOV

• May 4, 2023 · D

  Citation F0679

  Federal surveyors cited this nursing home on 2023-05-04 under CMS tag F0679 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide activities to meet all resident's needs. The deficiency was recorded as corrected on 2023-07-07. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-05-04.GOV

• May 4, 2023 · E

  Citation F0640

  Federal surveyors cited this nursing home on 2023-05-04 under CMS tag F0640 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. The deficiency was recorded as corrected on 2023-07-07. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2023-05-04.GOV

Penalties

Total fines on file: $0

Staffing

Latest: 4.08 nurse staffing hours per resident per day (2026-06-01)

Ownership

For profit - Limited Liability company

1. Parent organization: Bear Mountain Healthcare LLC

   parent · PAC 7517232572