Health inspection·December 1, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer medications in accordance with professional standards of practice for 3 of 3 residents reviewed for medication administration, Residents #6, #7 and #8. Residents Affected - Some Findings include: 1. Review of Resident #6's admission record revealed the resident was admitted with the diagnoses including nontraumatic acute subdural hemorrhage (bleeding in the brain), nontraumatic chronic subdural hemorrhage, pneumonia, seizures, dementia, essential primary hypertension, anxiety disorder, and major depression. Review of Resident #6's physician order dated 11/10/2023 reads, Amlodipine Besylate oral tablet 10 milligrams give one tablet by mouth one time a day related to essential primary hypertension hold for systolic BP [blood pressure] less than 110 and or heart rate less than 60. Review of Resident #6's physician order dated 11/10/2023 reads, Lisinopril oral tablet 10 milligrams give one tablet by mouth one time a day related to essential primary hypertension hold for systolic BP less than 110 and heart rate less than 60. Review of Resident #6's physician order dated 11/10/2023 reads, Levetiracetam oral tablet (Keppra) 500 mg [milligrams] give 1 tablet by mouth two times a day. Review of Resident #6's physician order dated 11/10/2023 reads, Doxycycline Hyclate 100 mg, give 100 mg by mouth every 12 hours for pneumonia for 6 days until finished. Review of Resident #6's Medication Administration Record for November 2023 for administration of Levetiracetam oral tablet (Keppra) 500 mg showed the medication was administered on 11/12/2023 at 12:37 AM (scheduled for 11/11/2023 at 9:00 PM), on 11/13/2023 at 12:49 PM (scheduled for 9:00 AM); on 11/14/2023 at 10:54 PM (scheduled for 9:00 PM); on 11/16/2023 at 3:31 PM (scheduled for 9:00 AM); on 11/17/2023 at 7:27 PM (scheduled for 9:00 AM); on 11/18/2023 at 12:31 AM (scheduled for 11/17/2023 at 9:00 PM); on 11/18/2023 at 11:22 AM (scheduled for 9:00 AM); on 11/19/2023 at 12:25 PM (scheduled for 9:00 AM); on 11/20/2023 at 10:46 PM (scheduled for 9:00 PM); on 11/22/2023 at 11:23 AM (scheduled for 9:00 AM); on 11/23/2023 at 1:18 PM (scheduled for 9:00 AM); on 11/24/2023 at 6:33 PM (scheduled for 9:00 AM) and at 11:21 PM (scheduled for 9:00 PM); on 11/27/2023 at 10:36 AM (scheduled for 9:00 AM); on 11/29/2023 at 11:22 AM (scheduled for 9:00 AM); and on 11/30/2023 at 10:18 PM (scheduled for 9:00 AM). Review of Resident #6's Medication Administration Record for November 2023 for administration of (continued on next page) 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 4 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 12/01/2023 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)