Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sixteen Acres Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
Food Storage and Kitchen Sanitation Deficiencies: The facility failed to maintain safe food handling practices in the main kitchen and unit kitchenettes. The ice machine had not been cleaned per the posted log, the ice scoop was stored on top of the machine, and debris was observed on the surface. In the unit kitchenettes, surveyors found unlabeled and undated beverages, raw hamburger patties not stored in a leak-proof container, expired and uncovered food items, a freezer with ice buildup and debris, and microwaves and food service surfaces with rust and dried food residue.
The facility failed to maintain infection control practices in the main laundry area and on a resident unit. Laundry staff sorted dirty linens, including towels soiled with feces, without the indicated PPE, and PPE was not available in the dirty linen sorting room. On Unit #2, a CNA entered and exited resident rooms with EBP signage posted without performing hand hygiene, including after incontinent care and after a mechanical lift transfer. The DON and UM stated that PPE and hand hygiene were required for these tasks.
A resident with chronic pain syndrome, hemiplegia/hemiparesis, lymphedema, and gait impairment used a motorized wheelchair but reported improved leg strength and asked to be assessed for standing, walker use, and possible ambulation. Although the resident expressed interest in restarting PT during a care plan meeting, no rehab assessment was completed for months, and the PT was not alerted until later. When the resident was finally evaluated, the resident stated a desire to move around with a walker and was able to ambulate two feet with mod assist.
Failure to Provide Timely Grooming Assistance: A resident with Parkinson's Disease, dementia, and severe cognitive impairment required total assistance for grooming, including nail care, per the care plan and task list. Surveyors repeatedly observed the resident's fingernails to be long with dark brown substance and food debris underneath while the resident ate with his/her hands, and both an HCP and facility staff stated the nails were dirty and should have been cleaned and trimmed.
A resident with a sacral pressure ulcer and aphasia did not receive a physician-ordered Morphine Sulfate oral solution via G-tube for six consecutive scheduled doses because the medication was not available from the pharmacy. The MAR and eMAR showed repeated missed administrations, and the UM and an RN confirmed the doses were not given while staff waited for delivery.
Improper Storage and Disposal of Refused Controlled Substance: A controlled substance was found unsecured in a medication cart on the 4th floor after a resident refused it earlier in the day. An LPN identified the tablet as oxycodone and stated it should have been destroyed immediately with another nurse, but it remained in a plastic medication cup in the cart instead of being secured in the controlled substance compartment or properly disposed of.
Incomplete MAR documentation showed that a resident with a sacral pressure ulcer and aphasia did not receive scheduled morphine doses because the oral solution was not available from the pharmacy. Staff documented that the medication was pending delivery, but the record did not consistently show that the PA/MD was notified of the missed doses, and the UM and nurse were unsure whether the issue had been reported.
A resident with a prior negative PASRR screen for SMI and diagnoses including depression and anxiety made a specific suicidal statement involving a butter knife. The facility implemented 1:1 supervision, crisis evaluation, and 15-minute checks, and an antipsychotic was re-ordered for irritability, anger, and violent behavior, but the record showed no PASRR referral after the significant change in condition.
The facility failed to maintain a homelike environment on Unit Four due to a leaking AC vent, resulting in water-stained ceiling tiles and a disposable incontinence pad with a caution sign placed in the hallway. Maintenance staff were aware of the issue, which persisted due to condensation during warmer weather, but no repairs were confirmed. The Director of Maintenance acknowledged the ongoing problem and its impact on the environment.
A facility failed to provide necessary transfer documentation for a resident with multiple mental health diagnoses during two hospital transfers. The required documentation, including advanced directives and provider information, was not completed or communicated, as per the facility's policy. The DON confirmed that essential forms and a transfer packet should have been sent with the resident, but there was no evidence that the receiving hospital received the appropriate documentation.
A facility failed to review the risks and benefits of bed rail use with a resident's guardian and did not obtain written consent before installation. The resident, diagnosed with Paranoid Schizophrenia, was under permanent guardianship. Despite facility policy requiring consent from legal representatives, the DON confirmed no documentation of attempts to contact the guardian for consent.
A facility failed to maintain accurate medical records by not ensuring a resident's Guardian signed the MOLST form, as required by the resident's guardianship status. The resident, diagnosed with Paranoid Schizophrenia, signed the form themselves, contrary to the facility's policy on advanced directives. The Director of Nursing admitted the oversight in consulting the Guardian for advanced directive decisions.
A facility failed to accurately code a resident's falls in the MDS Assessment. The resident, with Central Cord Syndrome and Unspecified Dementia, had documented falls during the look-back period, but the assessment indicated no falls. An MDS Nurse confirmed the coding error.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to follow professional standards of practice for food safety in the main kitchen and in three unit kitchenettes. In the main kitchen, the ice machine had not been cleaned since 9/7/25 according to the posted log, and the boxes for October, November, and December 2025 were blank. The ice scoop was stored on top of the ice machine instead of in a separate container. When the surveyor touched the top of the machine, dry brown dusty debris was observed on the fingertips. The Food Service Director stated the machine was new, that the scoop was stored on top because no separate bin came with it, and that the ice machine was supposed to be cleaned monthly. In Unit #2 kitchenette, the refrigerator contained a McDonald's plastic cup with a straw and clear liquid that was unlabeled and undated, and two raw hamburger patties dated 9/6/25 that were unlabeled and not in a leak-proof container. The microwave oven had flaking rusted areas on the inside of the door and inner cabinet casing. In Unit #3 kitchenette, the upper cabinet contained an Uncle Ben's Street Food microwaveable meal with a use-by date of 10/10/25, an uncovered container of unwrapped peppermint herbal tea bags with a use-by date of 7/2/21, and an open, undated gallon of spring water that was about one-quarter full. The freezer had a thick layer of ice covering the floor of the casing with blue, brown, and yellow particles. In Unit #4 kitchenette, the food service area below the microwave had splattered dried brown substance on the countertop, inside the top drawer, and down the cabinet surfaces. The microwave contained a red-brown substance with rice pieces crusted along the floor of the casing. The refrigerator contained a covered bowl of pale yellow soft product with a resident name and date of 12/5/25, a covered bowl of red liquid that was unlabeled and dated 12/5/25, and a clear produce bag of green grapes with a resident name that was undated. The Food Service Director stated dietary aides cleaned, restocked, and discarded outdated food and liquids twice daily, and the District Manager of Dining Services stated the findings were a concern, that foods and beverages should be labeled, dated, covered, and discarded on time, and that rusty microwave parts could flake into food.
Infection Control Failures in Laundry and Resident Care Areas
Penalty
Summary
The facility failed to maintain an infection prevention and control program in the main laundry area and on Unit #2. In the main laundry room, laundry personnel were observed sorting dirty linens, including towels soiled with feces, without wearing the indicated PPE such as gowns and eye protection. At the time of observation, no PPE supplies were available in the dirty linen sorting room, and laundry staff stated that PPE was kept elsewhere in the facility. The dirty linen sorting room also had a non-operational sink, with no paper towel dispenser or trash container nearby, and the area contained items such as a cloth, plastic wrapper, drywall screws box, paint brush, and dust around the sink. During the laundry observation, Laundry Personnel #2 was seen sorting the fecal-soiled linens without a gown or face shield. She stated that she should have worn PPE such as a gown and eye protection when sorting dirty linens to prevent transferring germs and pathogens into her clothing and from splashes. The DON stated that laundry personnel should don PPE when sorting soiled linens and that the dirty room should have appropriate PPE supplies and a functional sink with paper towels and a trash container for staff use. On Unit #2, CNA #1 was observed entering and exiting resident rooms with Enhanced Barrier Precautions signage posted without performing hand hygiene. CNA #1 also entered a resident room, assisted with incontinent care, and exited without hand hygiene, and later assisted another resident with a mechanical lift transfer and exited without hand hygiene. CNA #1 stated she did not complete hand hygiene because she was just entering and exiting the rooms and thought she may have used ABHR, but was not sure. The UM stated staff should use ABHR when entering and exiting a resident's room because staff may unintentionally touch surfaces and spread germs and infections.
Delayed PT Assessment for Walker and Gait Training
Penalty
Summary
The facility failed to provide necessary care and services in a timely manner to support a resident’s ability to carry out ADLs related to mobility. The resident was cognitively intact, had diagnoses including chronic pain syndrome, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, lymphedema, muscle wasting and atrophy, and abnormality of gait and mobility, and used a motorized wheelchair for mobility. The resident’s MDS showed partial/moderate assistance was needed for sit-to-stand and transfers, and the resident had previously received PT that ended in late 2024 with walking status listed as not applicable. At a care plan conference, the resident asked about rehabilitation services, standing, and use of a walker, and expressed interest in restarting PT. The care plan was revised to initiate a rehab screen as needed, but the clinical record did not show any evidence that Rehabilitation Services assessed the resident after the request. The resident later reported improved ability to move the legs, said the resident could now lift the legs into bed independently, and stated a desire to try standing with a walker and eventually walk, while still requiring the motorized wheelchair for independence with mobility. The Rehabilitation Director stated that a walker was not appropriate and safe for the resident and that if gait training was needed, a PT would complete the assessment, but the resident had not been assessed since the request. The PT stated the resident’s request was not brought to his attention until months later, and the resident was then evaluated for gait training. The PT evaluation documented that the resident wanted to move around with a walker, was able to ambulate two feet with moderate assistance, and had good rehabilitation potential.
Failure to Provide Timely Grooming Assistance
Penalty
Summary
The facility failed to ensure that Resident #14 was offered and/or provided timely grooming assistance for nail care. Resident #14 was admitted in June 2024 with diagnoses including Parkinson's Disease, dementia, left hand contracture, and lack of coordination. The MDS indicated the resident was unable to complete the BIMS, had severely impaired cognitive skills for daily decision making, and required substantial/maximal assistance with personal hygiene, including grooming. The care plan and Kardex both indicated the resident required assisted care of one staff for all grooming, and the task list showed personal hygiene/grooming was to be provided by a CNA every day and every shift. During survey observations on 12/3/25, 12/4/25, and 12/8/25, the resident was seen sitting up in bed, including while eating with his/her hands, and the fingernails on both hands were observed to be approximately 1/8 inch long with a dark brown substance and food debris underneath them. Nursing progress notes for November and December 2025 did not indicate refusal of grooming or personal hygiene care, and the December 2025 MAR did not document any behaviors from 12/1/25 to 12/8/25. The HCP stated the fingernails were long and dirty and wanted them cleaned and trimmed because it was unhygienic. Nurse #4 and CNA #2 both observed the dirty fingernails and stated they should have been cleaned, with CNA #2 adding that fingernails should be groomed daily or when observed to be soiled.
Ordered pain medication was unavailable for multiple scheduled doses
Penalty
Summary
The facility failed to ensure that a physician-ordered pain medication was available for Resident #4, who was admitted with diagnoses including a sacral pressure ulcer and aphasia and was unable to complete a BIMS assessment. The active order dated 12/8/25 directed Morphine Sulfate Oral Solution 10 mg/5 ml via G-tube every four hours for pressure ulcer pain management, with scheduled administration times of 1:00 A.M., 5:00 A.M., 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. The December 2025 MAR showed that the medication was not administered for six consecutive scheduled doses over two days: 12/7/25 at 1:00 P.M., 5:00 P.M., and 9:00 P.M., and 12/8/25 at 1:00 A.M., 5:00 A.M., and 9:00 A.M. eMAR notes documented that the medication was on order, not given because it was not available, and that staff were waiting for delivery from the pharmacy. During interview, the UM and Nurse #2 reviewed the MAR and confirmed the missed doses, stating the medication had not been administered because it was not available from the pharmacy and that pharmacy delivery issues were ongoing for the resident's Morphine Sulfate Oral Solution.
Improper Storage and Disposal of Refused Controlled Substance
Penalty
Summary
The facility failed to ensure that medications were stored according to professional standards of practice on the 4th floor unit. During a medication cart observation, a controlled substance was found in a plastic medication cup inside the top drawer of the medication cart rather than in a safe and secure compartment for controlled substances. The item was identified by Nurse #3 as an Oxycodone tablet, a Schedule II controlled substance. The Oxycodone tablet had been refused by a resident earlier in the day and was left in the medication cart. Nurse #3 stated that the tablet should have been destroyed immediately with another nurse when the resident refused it, but it was not destroyed. The nurse also stated that immediate destruction was needed to prevent medication errors and to maintain accuracy of the controlled substance count. During interviews, the Unit Manager and DON stated that refused controlled substance medication should be immediately destroyed and disposed of in the sharps container for safety so that other staff members and residents would not have access to it. The Unit Manager also stated that leaving the medication unsecured in the cart created the possibility that it could be forgotten or administered to another resident, and that failing to properly destroy it could affect the controlled substance count.
Incomplete documentation of provider notification for missed morphine doses
Penalty
Summary
Medical records were not complete and accurate for one resident because the facility did not document that the provider was notified when Morphine Sulfate Oral Solution was unavailable to be administered as ordered. The resident was admitted with diagnoses including a sacral pressure ulcer and aphasia, and the active physician order dated 12/8/25 directed Morphine Sulfate Oral Solution 10 mg/5 ml via G-tube every four hours for pain management related to the sacral pressure ulcer. The December 2025 MAR showed the medication was scheduled six times daily, but it was not documented as administered for three doses on 12/7/25 and three doses on 12/8/25. The eMAR notes documented that the medication was not given because it was not available from the pharmacy and that staff were waiting for delivery. One note stated the PA was okay to give the medication on arrival, and another stated the PA was aware, but the record did not show that the physician or PA had been notified for several of the missed doses. During interview, the Unit Manager and Nurse reviewed the MAR and stated the medication had not been administered because it was not available from the pharmacy, and they were unsure whether the pharmacy issue had been reported to the Administrator. The Unit Manager also stated she was unsure if the physician or PA had been notified and that there should have been a progress note or MAR documentation showing that notification.
Failure to Refer Resident for PASRR Review After Suicidal Statement
Penalty
Summary
The facility failed to refer one resident to the PASRR office after a significant change in status. The resident had a prior negative PASRR screening for SMI when admitted in March 2023 with diagnoses including intracranial injury with loss of consciousness, depression, and anxiety. The resident later became moderately cognitively impaired, was receiving antipsychotic medication, and had behavioral health follow-up for insomnia, inappropriate sexual behaviors, agitation, and aggression. The behavioral health note also documented a recent sibling loss and that the history of suicidal ideation was unknown, with Risperdal having been recently discontinued. On 9/16/25, the resident stated an intention to commit suicide with a butter knife or by any means necessary. The facility responded with removal of sharp objects, 1:1 supervision, crisis clinician evaluation, and 15-minute checks ordered by the on-call provider, with transfer to the ED if suicidal ideation continued. The next day, Risperidone was ordered again for irritability, anger, and violent behavior, and on 9/18/25 the physician recommended transfer to a psychiatric facility, which the legal guardian declined. The record did not show any PASRR referral after the suicidal statement and re-ordering of antipsychotic medication, and the social worker stated the facility had never referred the resident to PASRR for review related to the significant change for suicidal ideation.
Failure to Maintain a Homelike Environment Due to Leaking AC Vent
Penalty
Summary
The facility staff failed to maintain a clean, orderly, and homelike environment on Unit Four, as observed by the surveyor. A disposable incontinence pad was placed on the floor in the middle of the resident's hallway, topped with a yellow caution sign, indicating a water/slip hazard. This was due to a leaking air conditioning (AC) vent located on the ceiling, with water droplets dripping from the left side of the vent. The ceiling tiles around the AC vent were dark water-stained, with larger water-stained markings on the right side of the vent, spanning three tiles around the vent. During interviews, Maintenance Staff #1 and #2 acknowledged that the AC vent had been in this condition for a while, and they were unsure if any repairs had been made. The Director of Maintenance (DOM) confirmed that the ceiling vent leaks due to condensation during warmer weather, causing the ceiling tiles to become stained and requiring frequent replacement. The DOM admitted that the presence of the disposable pad, yellow hazard sign, stained tiles, and leaking AC vent did not contribute to a homelike environment. These conditions persisted throughout the survey period.
Failure to Provide Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated appropriately when transferring a resident to the emergency room. Specifically, the facility did not provide a form that included important information about the resident's medical history and the reason for transfer. This deficiency was identified for one resident out of a sample of 22. The facility's policy on Transfer/Discharge Notifications, revised in September 2022, requires documentation by the physician in the medical record, including the basis for the transfer and specific resident needs that cannot be met. Additionally, information provided to the receiving provider must include contact information for the practitioner responsible for the resident's care, resident representative information, advanced directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information to ensure a safe and effective transition of care. The resident involved had multiple diagnoses, including Schizoaffective Disorder, Conversion Disorder with seizures, Major Depressive Disorder, PTSD, Anxiety, and Borderline Personality Disorder. The resident was sent to the hospital on two occasions, and there was no documented evidence of discharge paperwork that included the resident's advanced directives, specific instructions or precautions for ongoing care, or provider information for the hospital transfers. During an interview, the DON acknowledged that the E-interact transfer form and/or a nurse's note should have been completed, and a transfer packet should have been sent with the resident, including physician's orders, advanced directives, pertinent labs, and the most recent progress note from the provider. However, there was no documented evidence that the receiving facility received the appropriate documentation during the transfers.
Failure to Obtain Guardian Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the risks and benefits of bed rail use were reviewed with the guardian of a resident diagnosed with Paranoid Schizophrenia, who was under a permanent guardianship. The resident was admitted to the facility in February 2024, and the use of side rails was initiated shortly after admission. However, the facility did not provide the guardian with information regarding the risks and benefits of using side rails, nor did they obtain written consent from the guardian before installing and using the bed rails. The facility's policy required obtaining consent from the resident or their legal representative after discussing potential benefits and risks. Despite this policy, the Director of Nursing confirmed that there was no documentation indicating that staff attempted to contact the resident's guardian to acquire consent for the use of side rails. The lack of documentation and communication with the guardian led to the deficiency identified during the survey.
Failure to Ensure Guardian Signature on MOLST Form
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with a diagnosis of Paranoid Schizophrenia. The resident had a court-appointed Permanent Guardian since 2000, as indicated by the Permanent Decree of Guardianship. However, the facility did not contact the Guardian to ensure that the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form was signed by the Guardian. Instead, the MOLST form was incorrectly signed by the resident shortly after their admission. The facility's policy on Massachusetts Advanced Directives requires that staff confirm and document the responsible parties for residents, which was not adhered to in this case. The Director of Nursing acknowledged that the resident should not have completed their own MOLST form and that the facility staff should have consulted with the Guardian regarding the resident's capacity to make advanced directive decisions. This oversight resulted in a failure to comply with accepted professional standards for maintaining medical records.
Inaccurate MDS Assessment Coding for Resident Falls
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) Assessment was accurately coded for a resident, leading to a deficiency. Specifically, the staff did not accurately code that the resident had falls on the most recent Quarterly MDS Assessment. The resident, who was admitted in August 2020, had diagnoses including Central Cord Syndrome and Unspecified Dementia. A review of the Quarterly MDS assessment indicated that the resident had no falls during the look-back period. However, the Nursing Progress Notes documented falls on three occasions during this period. During an interview, the MDS Nurse confirmed that the assessment was inaccurately coded and required modification.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loomis Lakeside At Reeds Landing | 1.8 mi | ★★★★★ | 0 | 0 |
| Chestnut Hill Health And Rehabilitation Center Llc | 2.8 mi | ★★★★★ | 0 | 0 |
| East Longmeadow Skilled Nursing Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Julian J Levitt Family Nursing Home | 3.1 mi | ★★★★★ | 0 | 0 |
| Care One At Redstone | 3.3 mi | ★★★★★ | 13 | 0 |
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