Springfield, MA

Sixteen Acres Health and Rehabilitation Center LLC

4-star overall rating with 4-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

215 Bicentennial Highway, Springfield, MA

(413) 796-7511

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

110

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Bear Mountain Healthcare

Operator or chain grouping

Approved since

1990-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.33

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.11

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.49

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.94

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.44

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.63

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.36

CMS adjusted RN staffing hours

Adjusted total hours

4.23

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

38%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,554

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

16.33

Composite VBP score used to determine payment impact.

Payment multiplier

0.9816

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.13

Baseline 22.06% · Performance 21.24% · Measure score 1.13 · Achievement 0 · Improvement 1.13

Healthcare-associated infections

Baseline 6.68% · Performance 8.64% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.42

Baseline 59.61% · Performance 45.63% · Measure score 4.42 · Achievement 4.42 · Improvement 3.52

Adjusted total nurse staffing

0.98

Baseline 3.78 hours · Performance 3.36 hours · Measure score 0.98 · Achievement 0.98 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.63%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 128 · Observed rate 14.06% · Lower 95% interval 9.27%
Discharge to community	45.17%	50.57% 5.4 pts worse	No Different than the National Rate · Eligible stays 117 · Observed rate 36.75% · Lower 95% interval 36.81%
Medicare spending per beneficiary	0.91	1.02 0.1 pts better
Drug regimen review with follow-up	95.31%	95.27% About the same	Numerator 61 · Denominator 64
Falls with major injury	3.13%	0.77% 2.4 pts worse	Numerator 2 · Denominator 64
Discharge self-care score	48.94%	53.69% 4.8 pts worse	Numerator 23 · Denominator 47
Discharge mobility score	38.3%	50.94% 12.6 pts worse	Numerator 18 · Denominator 47
Pressure ulcers or injuries, new or worsened	1.56%	2.29% 0.7 pts better	Numerator 1 · Denominator 64 · Adjusted rate 1.63%
Healthcare-associated infections requiring hospitalization	8.64%	7.12% 1.5 pts worse	No Different than the National Rate · Eligible stays 68 · Observed rate 13.24% · Lower 95% interval 5.47%
Staff COVID-19 vaccination coverage	6.94%	8.2% 1.3 pts worse	Numerator 12 · Denominator 173
Staff flu vaccination coverage	18.48%	42% 23.5 pts worse	Numerator 34 · Denominator 184
Discharge function score	51.06%	56.45% 5.4 pts worse	Numerator 24 · Denominator 47
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	97.14%	96.28% 0.9 pts better	Numerator 34 · Denominator 35
Resident COVID-19 vaccinations up to date	24%	25.2% 1.2 pts worse	Numerator 6 · Denominator 25

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.0	1.9 1.1 pts worse	1.9 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.6 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.5 0.3 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.3%	92.2% 6.1 pts better	93.4% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 97.7% · Q3 97.8% · Q4 98.9% · 4Q avg 98.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	91.8%	94.8% 3 pts worse	95.5% 3.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 91.8%
Percentage of long-stay residents experiencing one or more falls with major injury	1.4%	3.5% 2.1 pts better	3.3% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 0.0% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	12.0% 12 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	6.0%	5.2% 0.8 pts worse	5.4% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 11.2% · Q3 1.3% · Q4 2.5% · 4Q avg 6.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.2%	19.2% 2 pts better	19.6% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 19.8% · Q3 15.6% · Q4 14.8% · 4Q avg 17.2%
Percentage of long-stay residents who received an antipsychotic medication	5.6%	22.5% 16.9 pts better	16.7% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.2% · Q3 3.4% · Q4 7.0% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	21.9%	17.7% 4.2 pts worse	16.3% 5.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 29.1% · Q3 16.3% · Q4 17.5% · 4Q avg 21.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.4%	17.6% 3.2 pts better	14.9% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 10.1% · Q3 18.7% · Q4 12.7% · 4Q avg 14.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	1.0% 0.5 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.4%	2.0% 0.6 pts better	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.3% · Q3 0.0% · Q4 2.2% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.2%	21.7% 3.5 pts worse	19.8% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 19.8% · Q3 28.3% · Q4 25.4% · 4Q avg 25.2%
Percentage of long-stay residents with pressure ulcers	6.9%	4.6% 2.3 pts worse	5.1% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 9.6% · Q3 6.9% · Q4 5.4% · 4Q avg 6.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	65.8%	77.1% 11.3 pts worse	81.7% 15.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 61.4% · Q2 60.4% · Q3 76.2% · Q4 65.5% · 4Q avg 65.8%
Percentage of short-stay residents who had an outpatient emergency department visit	12.4%	11.8% 0.6 pts worse	12.0% 0.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 12.7% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.8%	1.3% 0.5 pts better	1.6% 0.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	64.3%	77.7% 13.4 pts worse	79.7% 15.4 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 64.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.7%	25.8% 1.9 pts worse	23.9% 3.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 27.3% · Expected 23.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-09 · Fire 2025-12-09

8 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-08-22 · Fire 2024-08-22

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-05-04 · Fire 2023-05-04

15 health deficiencies

Top issue: Resident Assessment and Care Planning (7 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-12-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-12-22

D · Potential for more than minimal harm 2025-12-09

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-12-22

D · Potential for more than minimal harm 2024-08-22

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-22

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-10-02

D · Potential for more than minimal harm 2024-08-22

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-10-02

E · Potential for more than minimal harm 2023-05-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-16

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-09

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2026-01-20

E · Potential for more than minimal harm 2025-12-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-20

D · Potential for more than minimal harm 2025-12-09

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2026-01-20

D · Potential for more than minimal harm 2025-12-09

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2026-01-20

D · Potential for more than minimal harm 2025-12-09

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2026-01-20

D · Potential for more than minimal harm 2025-12-09

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2026-01-20

D · Potential for more than minimal harm 2025-12-09

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2026-01-20

B · Minimal harm 2025-12-09

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2026-01-20

D · Potential for more than minimal harm 2024-08-22

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-10-05

D · Potential for more than minimal harm 2024-08-22

F622 · Resident Rights Deficiencies

Health

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.

Corrected 2024-10-05

D · Potential for more than minimal harm 2024-08-22

F700 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-10-05

D · Potential for more than minimal harm 2024-08-22

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-10-05

B · Minimal harm 2024-08-22

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-05

F · Potential for more than minimal harm 2023-05-04

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2023-07-07

F · Potential for more than minimal harm 2023-05-04

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2023-07-07

F · Potential for more than minimal harm 2023-05-04

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-05-04

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-05-04

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-05-04

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-05-04

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-07-07