Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.