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

Staffing

Hours and turnover

RN hours / resident day

0.33

Registered nurse staffing

LPN hours / resident day

1.11

Licensed practical nurse staffing

Aide hours / resident day

2.49

Nurse aide staffing

Weekend hours

3.63

Weekend nurse staffing

RN turnover

43%

Annual RN turnover

Total nurse turnover

38%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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