Hawthorne Center For Rehabilitation And Healing Of
HAWTHORNE CENTER FOR REHABILITATION AND HEALING OF in OCALA, FL — inspection on May 29, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #119's admission record showed Resident #119 diagnoses included altered mental status (onset date 4/3/2025), depression (onset date 4/8/2025), anxiety disorder (onset date 4/8/2025), brief psychotic disorder (onset date 4/8/2025) and major depressive disorder (onset date 4/3/2025).
Review of Resident #119's Level I Preadmission Screening and Resident Review (PASARR), dated 4/2/2026, showed no entry in section A. MI [mental illness] or suspected MI [mental illness].
During interview on 5/28/2026 at 11:43 AM, the Administrator confirmed Resident #119's Level I PASARR had not been updated to include mental health diagnoses.
Review of Resident # 70's admission record showed a diagnosis of Dementia with other diseases classified elsewhere mild, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety onset date 2/13/2026.
Review of Resident 70's PASARR dated 1/8/2026 was not revised to document a diagnosis of Dementia.
Record review of Resident #2s admission record showed diagnoses including vascular dementia onset date 5/09/2025 and major depressive disorder onset date 2/4/2026.
Review of Resident #2's Level I PASARR screening dated 5/08/2025 identified Resident #2 as diagnosed with Vascular dementia, the PASARR was not revised to reflect a diagnosis of major depressive disorder.
Review of Resident #5's admission record showed a diagnosis of PTSD (Post Traumatic Stress Syndrome) onset date 6/24/2022.
Review of Resident #5's Level I PASARR screening dated 2/16/2026 showed no documentation of PTSD.
During an interview on 5/27/2026 at 11:32 am, the Social Services Director stated, I don't sign the PASARR's, but do review them when directed to do so.
When a resident is first admitted , the Director of Nursing is the responsible one for the PASARR's.
During interview on 5/28/2026 at 11:43 am, the Administrator stated, The PASARR process should be an IDT (Interdisciplinary Team) approach.
Previously the Director of Nursing was responsible.
During interview on 5/29/2026 at 11:05 am, the Director of Nursing stated, I saw the issues with the PASARRs.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
Review of Resident #14's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASARR) dated 4/27/2026 documented bipolar disorder as a mental illness or suspected mental illness.
Review of Resident #14's medical admission record resident was admitted on [DATE] with diagnosis including but not limited to major depressive disorder recurrent [onset date 4/28/2026], other specified anxiety disorders [onset date 4/28/2026], and other bipolar disorder [onset date 4/28/2026].
Review of Resident #14's physician order dated 4/28/2026 read, Clonazepam oral tablet 1 MG [milligram] (Clonazepam) give 1 tablet by mouth one time a day for severe anxiety.
Review of Resident #14's physician order dated 4/28/2026 read, Bupropion HCI [hydrochloride] ER [extended release] (XL) Oral Tablet Extended Release 24 Hour 150 MG [milligram] (Bupropion HCI) Give 1 tablet by mouth one time a day for MMD [Major Depressive Disorder] Do not crush, chew, or split.
During an interview on 5/29/2026 at 8:30 AM, the Director of Nursing stated, [Resident #14's Name]'s PASSAR should have been reviewed and corrected to reflect all the diagnoses.
Review of the policy and procedure titled Pre-admission Screening and Resident Review (PASRR) last approval date of 1/22/2026 read, The Admissions Coordinator/Designee is responsible for ensuring that the Level I PASRR Screen and Level II PASRR Evaluation and Determination, if applicable, are completed prior to admission.
Procedure: 2. A level I PASRR must be fully and accurately complete and distributed in accordance with Rule 59G-1.040,F.A.,C.
Upon or prior to admission, if the facility finds the Level I to be incomplete or inaccurate, a corrected Level I PASRR must be completed by hospital staff or appropriate Nursing Facility staff (physician, RN, MSW, or LCSW) or KEPRO staff.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
Review of the facility policy and procedure titled Summit Care Resident Assessment Instrument
Purpose: To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI), and to comply with state and federal regulations.
Policy Statement: The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care.
This process will involve interdisciplinary team members and be revised to reflect resident condition changes.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
During an interview on 5/27/2026 at 1:55 PM Staff M, Licensed Practical Nurse (LPN) stated, He does have that order for clonidine. No, I don't see that I did administer it. I should have.
During an interview on 5/28/2026 at 6:45 AM the Director of Nursing (DON) stated, All orders should be followed.
Review of the policy and procedure titled, Medication Administration General Guidelines approval date of 1/22/2026 read, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so.
Procedure: B.
Administration: 2).
Medications are administered in accordance with written orders of the prescriber.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
During an observation on 5/28/2026 at 8:37 AM the DON confirmed Resident #116 oxygen was being administered at 4 liters per minute.
During an observation on 5/26/2026 at 10:37 AM Resident #130 was lying in bed oxygen was being administered at 1.5 liters per minute via nasal cannula.
There was no date on tubing.
During an observation on 5/26/2026 at 12:10 PM Resident #130 was sitting up in a wheelchair.
Oxygen was being administered at 1.5 liters per minute via nasal cannula.
Oxygen tubing was dated 5/26.
Review of Resident #130's physician orders did not document oxygen orders.
During an interview on 5/27/2026 at 11:46 AM, Staff D, Licensed Practical Nurse stated, I do not see an order for oxygen.
She [Resident #130] would need one for the nasal cannula and the liters of oxygen. I will have to contact the provider and get an order.
During an interview on 5/27/2026 at 11:46 AM, Staff D, LPN, confirmed Resident #130 was resting in bed with eyes closed, oxygen at 2 liters per minute via nasal cannula.
During an interview on 5/27/2026 at 8:28 AM, the Director of Nursing stated, Doctors orders need to be in place for oxygen.
Review of the facility policy and procedure titled, Oxygen Administration, last approval date of 1/22/2026 read, Purpose: The purpose of this procedure is to provide guidelines for oxygen administration.
Procedure: 7.
Turn on the oxygen.
Start the flow of oxygen at the prescribed rate. 9.
Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
Review of Resident #108's physician order dated 05/20/2026 read, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for Hypotension Hold for SBP greater than 120.
Review of Resident #108's MAR [medication administration record] for May 2026 read, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for hypotension Hold for SBP greater than 120 D/C [discontinue] Date 05/20/2026 2135 [9:35 PM].Review of Resident #108's MAR for May 2026 revealed that on 05/01/2026, Resident #108's Blood Pressure (B/P) was documented as 132/84 and midodrine was administered at 1400 [2:00 PM], on 05/03/2026, B/P was 130/81 and midodrine was administered at 1400, on 05/06/2026, B/P was documented as 130/72 and midodrine was administered at 0600 [6:00 AM], on 05/10/2026, B/P was documented as 140/72 and midodrine was administered at 2200 [10:00 PM], on 05/11/2026, B/P was documented as 132/70 and midodrine was administered at 0600, on 05/11/2026, B/P was documented as 121/61 and midodrine was administered at 1400, on 05/11/2026, B/P was documented as 126/74 and midodrine was administered at 2200, on 05/12/2026, B/P was documented as 122/70 and midodrine was administered at 0600, on 05/12/2026, B/P was documented as 129/68 and midodrine was administered at 1400, on 05/13/2026, B/P was documented as 122/75 and midodrine was administered at 2200, on 05/14/2026, B/P was documented as 131/73 and midodrine was administered at 1400, on 05/15/2026, B/P was documented as 136/69 and midodrine was administered at 1400, on 05/17/2026, B/P was documented as 134/72 and midodrine was administered at 2200, on 05/18/2026, B/P was documented as 134/70 and midodrine was at 2200, on 05/21/2026, B/P was documented as 130/70 and midodrine was administered at 1400, 05/21/2026, B/P was documented as 145/78 and midodrine was administered at 2200, on 05/23/2026, B/P 145/65 and midodrine was administered at 1400, on 05/23/2026, B/P was 126/62 and midodrine was administered at 2200, on 05/24/2026, B/P was documented as 121/66 and midodrine was administered at 0600, on 05/24/2026, B/P was documented as 121/66 and midodrine was administered at 1400, on 05/27/2026, B/P was documented as 124/62 and midodrine was administered at 0600,During an interview on 05/28/2026 at 3:10 PM, Staff K, RN (Registered Nurse) stated, A check mark on the MAR means that a medication was administered. I don't know why there is a checkmark. I always check the parameters for medications. If I hold a medication, I document a number in the MAR and a nursing note. I am not sure what happened with [Resident #108's Name]'s midodrine.
During an interview on 05/28/2026 at 12:55 PM, the Director of Nursing stated, The checkmark on the MAR means that a medication was given.
When a nurse is holding midodrine per parameters they should document a number in the MAR, not a checkmark.
The nurses should not have administered the medication if the blood pressure is outside of parameters.
Review of policy and procedure titled, Nursing Policies- Medication Administration Guidelines reviewed on 01/22/2026 read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. B.
Administration 1) Medications are administered in accordance with written orders of the prescriber.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
Review of the policy titled Food Handling, last reviewed 1/22/2026, read Food shall be handled in a proper method to ensure retention of flavor, appearance, quality, nutrients, and to safeguard against contamination.
The policy specified 3.
When it is necessary for staff to touch food during preparation, they must wash their hands immediately before beginning the process.
Disposable gloves are used.
Review of policy titled Storage of Perishable Goods, last reviewed 1/22/2026, 1.
Freezer temperatures are maintained at a level to keep frozen food solid.
Stored frozen foods shall be maintained frozen.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
Review of the facility policy and procedure titled Ongoing Assessment, Site Care, and Dressing Change with a last review date 1/22/2026 read, Policy: Transparent semipermeable membrane (TSM) dressing are changed every 5-7 days.
105602 05/29/2026
Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474
During an interview on 5/28/2026
Guidelines last approval; date of 1/22/2026 read, Policy: Medications are administered as prescribed
so.
Procedure: A).
Preparation: 2.
Handwashing and hand sanitization: The person administering medications adheres to good hand hygiene, which includes sanitizing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident. B.
Administration: 2).
Medications are administered in accordance with written orders of the prescriber. 9).
Hands are sanitized before putting on examination gloves and upon removal for administration of topical, ophthalmic, injectable, enteral, rectal, and vaginal medications.
Review of the policy and procedure titled, Handwashing/Hand Hygiene last approval date of 1/22/2026 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection.
Policy Interpretation and Implementation: 2.
All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5.
Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non anti-microbial) and water for the following situations: b.
Before and after direct contact with residents; c.
Before preparing or handling medications; i.
After contact with residents intact skin; m.
After removing gloves. 6.
Hand hygiene is the final step after removing and disposing of personal protective equipment. 7.
The use of gloves does not replace hand washing/hand hygiene.
Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare- associated infections.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.