Facility profile · CCN 225392
Sixteen Acres Health And Rehabilitation Center Llc
28 federal citations on record .
Record summary
Federal record · Q1 202628
Total citations
28
Last 3 years
0
Actual harm+
0
Federal penalties
$0
Total fines
4
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
28 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Dec 9, 2025 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Dec 9, 2025 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Dec 9, 2025 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Dec 9, 2025 | F761 | 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. | D | Standard |
| Dec 9, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard |
| Dec 9, 2025 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Dec 9, 2025 | F676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Standard |
| Dec 9, 2025 | F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | B | Standard |
| Aug 22, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Aug 22, 2024 | F700 | 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. | D | Standard |
| Aug 22, 2024 | F641 | Ensure each resident receives an accurate assessment. | B | Standard |
| Aug 22, 2024 | F622 | 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. | D | Standard |
| Aug 22, 2024 | F584 | 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. | D | Standard |
| May 4, 2023 | F926 | Have policies on smoking. | D | Standard |
| May 4, 2023 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| May 4, 2023 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | F | Standard |
| May 4, 2023 | F699 | Provide care or services that was trauma informed and/or culturally competent. | D | Standard |
| May 4, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| May 4, 2023 | F679 | Provide activities to meet all resident's needs. | D | Standard |
| May 4, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| May 4, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard |
| May 4, 2023 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
| May 4, 2023 | F640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | E | Standard |
| May 4, 2023 | F638 | Assure that each resident’s assessment is updated at least once every 3 months. | F | Standard |
| May 4, 2023 | F637 | Assess the resident when there is a significant change in condition | D | Standard |
| May 4, 2023 | F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | F | Standard |
| May 4, 2023 | F625 | 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. | E | Standard |
| May 4, 2023 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | E | Standard |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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