Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure a PASRR (Pre-admission Screening and Resident
Review) Level I was completed to determine if a newly admitted resident had or may have a mental
disorder or related conditions prior to admission for 1 of 3 residents, Resident #49.
Residents Affected - Few
Findings include:
Review of Resident #49's admission record documented Resident #49 was admitted on [DATE]. On
6/24/2022 the resident was diagnosed with adjustment disorder, psychotic disorder with hallucinations, and
post-traumatic stress disorder.
Review of Resident #49's medical record did not contain a Level 1 PASRR.
Review of Resident #49's care plan, initiated on 9/11/2022, read, [Resident #49's name] has a behavior
problem consist of paranoia, and is non-compliant with instructions for safety. [Resident #49's name] has a
mood problem r/t [related to] Admission, PTSD [Post Traumatic Stress Disorder], Adjustment D/O
[disorder], Anxiety, Depression, Psychotic-Hallucinations.
During an interview on 10/4/2023 at 12:02 PM, the Administrator stated I do not have one [PASRR], we had
a waiver. The DON [Director of Nursing] would need to know about the PTSD.
During an interview on 10/4/2023 at 12:40 PM, the Director of Nursing stated, I was not working here
during that time. [Resident #49's name] should have had a PASRR upon admission and once diagnosed
with PTSD she should have had a reassessment.
Review of the policy and procedures titled Admission/Social Services-Pre-admission Screening and
Resident Review (PASRR), last reviewed 12/30/2022 the policy read, The purpose of PASRR is to ensure
individuals who are being considered for placement in a Nursing Facility are evaluated for serious mental
illness and/or intellectual disability and are offered the most integrated setting appropriate for their long
term care needs (including determining whether a Nursing Facility is appropriate). All persons, regardless
of payer or age, needing admission to a Nursing Facility must first be screened for possible metal illness or
the presence of an intellectual disability (ID) or both (Level I). If a mental illness (MI) or intellectual disability
(ID) appears to exist, the person must be referred for further evaluation (Level I) before Nursing Facility
admission. The Level I PASRR screen must be done prior to admission for all persons seeking admission to
the facility.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
105602
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105602
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hawthorne Center for Rehabilitation and Healing Of
4100 SW 33rd Ave
Ocala, FL 34474
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on interview and record review the facility failed to implement the resident centered care plan
interventions related to nutrition for 1 of 4 residents, Resident #31.
Residents Affected - Few
Findings include:
Review of Resident #31's care plan, date initiated 5/10/2021, documented Resident #31 was at risk for
malnutrition related to Parkinson's disease, atrial fibrillation, congestive heart failure, depression and
modified diet. Resident #31's care plan documented a history of significant weight fluctuations and impaired
skin integrity. Under interventions the care plan documented nutritional interventions to include Weights as
directed.
Review of Resident #31's physician's orders, documented an order dated 2/3/2022, which read Weekly
weights.
Review of Resident #31's weight records documented dated 12/06/2022 the resident weighed 141.6
pounds, dated 04/01/2023 the resident weighed 133 pounds, dated 08/04/2023 the resident weighed 118.8
pounds, dated 09/06/2023 the resident weighed 115.2 pounds for a total weight loss of 18.64%.
Review of Resident #31's weight records documented weights were not done weekly as ordered by the
physician and as specified in the care plan to complete Weights as directed.
During an interview on 10/4/2023 beginning at 11:34 AM, the Registered Dietician confirmed Resident #31
was at risk for weight loss and had required interventions such as fortified foods and double portions at
dinner. She stated the advantage of obtaining Resident #31's weights weekly would be that the weekly
weights could be used to determine Resident #31's overall nutritional status and needs.
During an interview on 10/4/2023 at 12:26 PM, the Director of Nursing stated the facility had not been
obtaining Resident #31's weights as indicated in the care plan and as ordered by the physician. The
physician's order was not correctly entered into the computer and did not trigger to be on Resident #31's
medication administration record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105602
If continuation sheet
Page 2 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105602
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hawthorne Center for Rehabilitation and Healing Of
4100 SW 33rd Ave
Ocala, FL 34474
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure respiratory care services were
provided consistent with professional standards of practice for oxygen administration for 1 of 2 residents,
Resident #92, reviewed for continuous oxygen administration therapy.
Residents Affected - Few
Findings include:
During an observation on 10/02/23 at 10:01 AM, Resident #92 was lying in bed with oxygen being
administered via nasal cannula at 5 Liters per minute.
Review of Resident #92 admission record documented the resident was admitted on [DATE] with diagnosis
to include acute and chronic respiratory failure with hypoxia, pleural effusion, chronic obstructive pulmonary
disease, and personal history of other malignant neoplasm of bronchus and lung.
Review of Resident #92's physician order dated 7/18/2023 read, Oxygen @ 3L/Min via NC [at 3 liters per
minute via nasal cannula] continuous inhalation.
During an observation on 10/3/2023 at 8:00 AM, Resident #92 was lying in bed with oxygen being
administered via nasal cannula at 5 liters per minute.
During an observation on 10/3/2023 at 12:04 PM, Resident #92 was sitting up in bed having lunch, oxygen
was being administered at 5 liters via nasal cannula and the humidifier container [a refillable plastic bottle
that infuses the normal flow of oxygen with water droplets. Using oxygen regularly may dry out the nasal
passages, throat and mouth, a humidifier can help alleviate these symptoms and make oxygen therapy
more comfortable] was empty.
During an interview on 10/3/2023 at 12:07 Staff D, License Practical Nurse (LPN) stated, Sometimes the
resident [Resident #92] will ask any random person to change it for him [the oxygen setting]. I was there
and gave him his meds and he didn't tell me anything. The oxygen is 5 liters, and it should be 3 liters. I will
replace the humidifier container, it is empty.
During an interview on 10/3/2023 at 12:10 PM, Resident #92 stated, I do not remember asking someone to
change my oxygen rate.
During an interview on 10/3/2023 at 12:15 PM, the Director of Nursing stated, Nurses should be looking
and making sure the flow rate is accurate. If the resident needs more oxygen, then the doctor should be
contacted to get an order to increase it. Only nurses are able to change oxygen with an order.
Review of the policy and procedure titled Nursing-Oxygen Administration, last reviewed 12/30/2022 read,
Purpose: The purpose of this procedure is to provide guidelines for oxygen administration. Procedure: 7.
Turn on the oxygen. Start flow of oxygen at the prescribed rate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105602
If continuation sheet
Page 3 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105602
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hawthorne Center for Rehabilitation and Healing Of
4100 SW 33rd Ave
Ocala, FL 34474
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure residents' PRN (Pro Re Nata, as needed) orders for
psychotropic drugs are limited to 14 days for 2 of 8 residents, Residents #36 and #73, reviewed for
behavioral monitoring.
Findings include:
Review of Resident #36's electronic health record documented the resident was admitted on [DATE] with
diagnoses to include Alzheimer's disease with late onset, hypertension, atherosclerosis heart disease,
anemia, anxiety disorder, dementia, and major depressive disorder.
Review of Resident #36's Physician orders dated 9/5/23 read, Lorazepam .5 mg [milligrams] - give .5 mg by
mouth every 8 hours as needed for anxiety.
Review of Resident #73's electronic health record documented the resident was admitted on [DATE] with
diagnoses to include dementia, psychosis, generalized anxiety, Type II Diabetes Mellitus, and
atherosclerotic heart disease.
Review of Resident #73's Physician orders dated 8/18/23 read, Ativan, Benadryl, Haldol 1 mg -12.5 mg -1
mg apply one ml [milliliter] topically prn for behaviors.
During an interview conducted on 10/3/23 at 11:20 AM the Director of Nursing confirmed Resident #36 and
#73 both had PRN orders for psychotropic medications which had extended past 14 days without written
documentation from the physician.
Review of the policy and procedure titled, Psychotropic PRN (as needed) Medication, last reviewed on
12/30/22 read, Policy .PRN orders for psychotropic drugs are limited to 14 days, except when the attending
physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond
14 days. Then he or she should document the rationale in the resident's medical record and indicate the
duration for the PRN order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105602
If continuation sheet
Page 4 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105602
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hawthorne Center for Rehabilitation and Healing Of
4100 SW 33rd Ave
Ocala, FL 34474
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure drugs and biologicals used in the
facility were stored and labeled in accordance with currently accepted professional principles for 2 of 5
medication carts.
Findings include:
During an observation on [DATE] at 9:20 AM with Staff A, LPN (License Practical Nurse) of the Bounce
Back Lane medication cart there were a total of 11 loose pills in the medication cart in the drawers
containing the medication blister packs.
During an interview on [DATE] at 9:24 AM, Staff A, LPN stated, Loose medication should not be in the
medication cart, you do not know who it belongs to. The medication should be disposed of.
During observation on [DATE] at 9:46 AM with Staff C, LPN of the Liberty Lane medication cart there was
one vial of Procrit not in the original pharmacy packaging, one open bottle of artificial eye drops with no
open date or expiration date, one open bottle of Timolol 0.5% eye drops with no open or expiration date,
one open Tregely Ellipta inhaler and one open Breo Ellipta inhaler with no open or expiration dates and
three loose medications in the drawers containing the medication blister packs.
During an interview on [DATE] at 9:54 AM, Staff C, LPN stated I do not know why the vial is there like this. I
received the medication cart this morning and it was that way. We should date medication when open and
expired. We should check the cart and remove all loose medication and dispose of them using the drug
buster we use.
During an interview on [DATE] at 12:21 PM, the Director of Nursing (DON) stated Medication should be
properly dated when opened with an open date and an expiration date. The cart should be maintained
clean and have no loose pills. Medication should be replaced and discarded appropriately. We have drug
busters to dispose of medication if it is a narcotic the staff should dispose of the medication accordingly.
Review of the policy and procedure titled Medication Storage, last review date of [DATE], read, Policy.
Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of
the residents and is in accordance with FL [Florida] Department of Health guidelines. Procedures: C.
Medications will be stored in an orderly, organized manner in a clean area. E. Medications will be stored in
the original, labeled containers received from the pharmacy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105602
If continuation sheet
Page 5 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105602
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hawthorne Center for Rehabilitation and Healing Of
4100 SW 33rd Ave
Ocala, FL 34474
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on interview and record review the facility failed to ensure accurate documentation for insulin
administered for 1 of 4 residents, Resident #30, reviewed for insulin administration.
Residents Affected - Few
Findings include:
Review of Resident #30's physician orders, dated 10/02/2023, read, Humalog Injection Solution 100 unit/ml
[milliliter] (Insulin Lispro) inject per sliding scale: if 150-200=2, units; 201-250=4 units; 251-300=6 units;
301-350=8 units; 351-400=10 units; 401+- Notify MD [Medical Doctor]. Notify physician for Blood Glucose
Greater Than 400, subcutaneously before meals and at bedtime for DM (Diabetes).
Review of Resident #30's medication administration record (MAR) for the month of August 2023
documented the resident would refuse the blood glucose checks at least once a day. When the resident
permitted the glucose checks the glucose results, per the physician's orders, resulted in the administration
of Humalog insulin. The MAR did not document the number of units of insulin that were administered to the
resident.
Review of Resident #30 MAR for the month of September 2023 documented the resident would refuse the
blood glucose checks at least once a day. When the resident permitted the glucose checks the glucose
results, per the physician's orders, resulted in the administration of Humalog insulin. The MAR did not
document the number of units of insulin that were administered to the resident.
During an interview at 10/2/2023 at 12:02 PM, the Director of Nursing stated, The nurse input the order
wrong. The staff were doing the blood glucose checks and insulin coverage, but they were not documenting
the units since the order was written and marked as no documentation required.
Review of the policy and procedure titled Nursing-Documentation, Clinical, lasted reviewed 12/30/2022,
read, Purpose: The facility clinical staff will document the provision of care and services according to
nursing standards and regulatory requirements. When completed, documentation will accurately reflect the
clinical care and other services provided to the resident and ensure that the appropriate information is
available to all interdisciplinary team members.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105602
If continuation sheet
Page 6 of 6
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
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.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
FAQ · About this visit
Common questions about this visit
What happened during the October 5, 2023 survey of HAWTHORNE CENTER FOR REHABILITATION AND HEALING OF?
This was a inspection survey of HAWTHORNE CENTER FOR REHABILITATION AND HEALING OF on October 5, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HAWTHORNE CENTER FOR REHABILITATION AND HEALING OF on October 5, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.