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Deficiency Records for Sixteen Acres Health and Rehabilitation Center LLC

View the most recent health deficiencies and inspection results for Sixteen Acres Health and Rehabilitation Center LLC. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Sixteen Acres Health and Rehabilitation Center LLC. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2025-12-09 2026-01-20 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2025-12-09 2026-01-20 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2025-12-09 2026-01-20 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2025-12-09 2026-01-20 N
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. Health 2025-12-09 2026-01-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-12-09 2026-01-20 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-12-09 2026-01-20 N
Provide and implement an infection prevention and control program. Health 2025-12-09 2026-01-20 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2025-12-09 2025-12-22 N
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. Fire Safety 2025-12-09 2025-12-22 N
Ensure each resident receives an accurate assessment. Health 2024-08-22 2024-10-05 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-08-22 2024-10-05 N
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. Health 2024-08-22 2024-10-05 N
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. Health 2024-08-22 2024-10-05 N
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. Health 2024-08-22 2024-10-05 N
Provide a written emergency evacuation plan. Fire Safety 2024-08-22 2024-10-02 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-08-22 2024-10-02 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-08-22 2024-10-02 N
Provide properly protected cooking facilities. Fire Safety 2024-08-22 2024-10-02 N
Have policies on smoking. Health 2023-05-04 2023-07-07 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-05-04 2023-07-07 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-05-04 2023-07-07 N
Provide care or services that was trauma informed and/or culturally competent. Health 2023-05-04 2023-07-07 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-05-04 2023-07-07 N
Provide activities to meet all resident's needs. Health 2023-05-04 2023-07-07 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-05-04 2023-07-07 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-05-04 2023-07-07 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-05-04 2023-07-07 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2023-05-04 2023-07-07 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2023-05-04 2023-07-07 N
Assess the resident when there is a significant change in condition Health 2023-05-04 2023-07-07 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2023-05-04 2023-07-07 N
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. Health 2023-05-04 2023-07-07 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-05-04 2023-07-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-05-04 2023-06-16 N

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