No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Hawthorne Center For Rehabilitation And Healing Of

4100 SW 33rd Ave, Ocala, FL 34474 · For profit - Limited Liability company · 120 certified beds · (352) 237-7776 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$157,729 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $157,729 in federal fines (most recent 2025-06-17)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)
  • about 17% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
3300 Southwest 34th Avenue, Suite 140
Pharmacy
2575 Sw 42nd St Unit 100 · (352) 237-3648 · Call to confirm hours
Grocery
2575 Sw 42nd St Unit 100 · (352) 237-7186 · Call to confirm hours
Park
Paddock Park · Typically dawn to dusk
Place of worship
3300 SW 34th Ave · (352) 861-5577

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.8%8.7%15.4%better
Long-stay residents who lose too much weight8.4%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.2%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.0%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.6%2.5%3.3%better
Long-stay residents whose ability to walk worsened17.0%9.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication6.2%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers2.8%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control7.3%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table2.2%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine91.6%94.7%79.4%better
Short-stay residents rehospitalized after admission28.8%26.1%22.6%worse
Short-stay residents with an outpatient ER visit9.5%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.072.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.531.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 232 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.3%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
55.9%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 55.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 161 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.3%CMS range 43.8–55.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.8–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.7–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.45
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.19
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.25
RN hoursweekends
56.7%
Total nursing turnover
63.6%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 110.7 residents a day — about 92% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.80 on weekdays — 14% thinner on weekends. RN hours go from 0.53 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-05-29)
4
at the previous standard inspection (2025-01-16)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2025-06-17 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of policy and procedures, the facility failed to ensure residents with prescribed controlled medications were administered the medications per the physician order when failing to contact the physician when prescriptions were needed and the medications were not administered for three of three residents reviewed for medication administration (Residents #7, #9, and #10). Resident #7, with a history of prescribed Alprazolam use, was admitted into the facility on 6/11/2025 and had been prescribed Alprazolam four times a day. Resident #7 suffered withdrawal symptoms of sweating, shaking, insomnia, and increased pain. There was a delay in administering Alprazolam until 6/13/2025 at 9:00 PM resulting in nine missed doses. Resident #9, with a history of prescribed Alprazolam use, was admitted into the facility on 5/20/2025 and was prescribed Alprazolam once a day. Resident #9 was not administered Alprazolam until 5/24/2025 resulting in three missed doses. Resident #10, a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2025-06-17 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical wellbeing of each resident by failing to implement policy and procedures for medication administration. The facility failed to ensure residents with prescribed controlled medications were administered the medications per the physician order when failing to contact the physician when prescriptions were needed and the medications were not administered for three of three residents reviewed( Residents #7, #9, and #10). Resident #7, with a history of prescribed Alprazolam use, was admitted into the facility on 6/11/2025 and had been prescribed Alprazolam four times a day. Resident #7 suffered withdrawal symptoms of sweating, shaking, insomnia, and increased pain. There was a delay in administering Alprazolam until 6/13/2025 at 9:00 PM resulting in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to administer oxygen at the correct flow rate according to physician orders for 2 residents ( Resident #58 and #116) and failed to have physician orders documenting the prescribed flow rate for 1 resident ( Resident #130) of 5 residents reviewed for oxygen therapy. Findings include: During an observation on 5/26/2026 at 10:49 AM Resident #58 was observed with oxygen at 3 liters via a nasal cannula. During and observation on 5/27/2026 at 7:26 AM Resident #58 was observed with oxygen at 3 liters via a nasal cannula. Review of Resident #58's admission record document diagnosis that include unspecified diastolic congestive heart failure, morbid severe obesity due to excess calories, protein calorie malnutrition, acute and chronic respiratory failure with hypoxia, asthma, cardiomegaly, atherosclerotic heart disease of native coronary artery without angina pectoris, age-related osteoporosis without current pathological fracture, anxiety disorder, hyperlipidemia, insomnia, essential primary hypertension and major…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation interview and record review the facility failed to ensure food was stored and served in a sanitary manner. Findings include: Observation of the walk in freezer on 5/26/2026 at 9:34 AM showed there was no stand alone thermometer in the walk-in freezer. During interview on 5/26/2026 at 9:35 AM, the Certified Dietary Manager confirmed there was no stand alone thermometer in the walk-in freezer. Service of the midday meal was observed on 5/29/2026 beginning at 11:20 AM. The cook was observed using a gloved hand to scoop and place meal items onto plates and touching the counter top. The cook was then observed lifting a cheese slice from a stack of cheese with her same gloved hand and placing the slice of cheese onto a hamburger bun for service to a resident. Throughout the meal service, while plating meal items to be served to residents, the cook was observed placing her hand on the food contact surface of 4 plates. The cook was also observed doffing used gloves and donning new gloves without washing her hands after doffing gloves. During interview on 5/29/2026…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-29 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure assessments were updated following documentation of a new diagnosis for 4 Residents (Resident #2, 5, 70, and 119) out of 10 Residents sampled for preadmission screening and resident reviews (PASARR). Findings include: 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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure assessments were accurately and completely documented for 3 residents (Resident #7, #129, and #14) of 10 sampled for preadmission screening and resident review. Findings include: Review of Resident #7's admission record documented diagnoses that include non-ST elevation myocardial infarction, chronic obstructive pulmonary disease with acute exacerbation, pneumonia, protein calorie malnutrition, chronic respiratory failure with hypoxia, chronic pain syndrome, and idiopathic peripheral autonomic neuropathy. Review of Resident #7's physician order dated 4/24/2026 read, psych consult. Review of Resident #7's physician order dated 3/19/2026 read, Amitriptyline HCl Oral Tablet 25 MG (Amitriptyline HCl) Give 25 mg by mouth at bedtime for Mdd (major depressive disorder). Review of Resident #7's psychiatric note dated 5/8/2026 read, Note Type: Balanced Wellbeing Psychiatry Subsequent Note. Patient admit date : [DATE] Chief Complaint: Depression, anxiety…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive care plan for 1 (Resident #14) of 7 residents reviewed for medication management and for 1 (Resident #58) of 5 residents reviewed for respiratory services. Findings include: Review of Resident #14's care plan did not document a focus for anxiety or antianxiety medication. Review of Resident #14's medical record resident was admitted on [DATE] with diagnoses including but not limited to major depressive disorder [onset date 4/28/2026], anxiety disorders [onset date 4/28/2026], and 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] give 1 tablet by mouth one time a day for severe anxiety. Review of Resident #14's physician order dated 5/1/2026 read, Clonazepam Oral Tablet 0.5 MG give 0.5 mg by mouth in the morning for anxiety. Review of Resident #14's physician order dated 5/11/2026 read, Clonazepam Oral Tablet 0.5 MG give 1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide dressing changes and have orders for flushing of intravenous catheters for 1 (Resident#32) of 3 residents reviewed for intravenous infusions, the facility failed to perform weekly skin observations for 1 (Resident #50) of 6 residents reviewed for skin conditions, the facility failed to provide daily weights for 1 Resident (Resident #45) out of 4 Residents reviewed for weights and failed to administer medication appropriately for 1 (Resident #103) of 7 residents reviewed for medication management. Findings include: During an observation on 5/26/2026 at 10:14 AM, Resident #32 was lying in bed PICC [peripherally inserted central catheter] line dressing dated 5/6/2026. The dressing was intact. The site was not red or swollen. During an interview on 5/26/2026 at 10:14 AM, Resident #32 stated she was getting antibiotics for wound infection of a wound in her back which she was admitted with. She was unable to recall when the last time…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-29 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the resident's medication regimen remained free from unnecessary medications by administering midodrine outside of physician ordered parameters for 1 (Resident #108) of 7 residents reviewed for unnecessary medications. Findings include: Review of Resident #108's physician order dated 03/13/2026 read, Midodrine HCl [hydrochloride] Oral Tablet 5 MG [milligrams] (Midodrine HCl) [medication used to increase blood pressure] Give 1 tablet by mouth three times a day for hypotension [low blood pressure] Hold for SBP [systolic blood pressure] greater than 120. 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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility to ensure complete and accurate records were provided for 2 (Residents #8 and #32) of 6 residents, reviewed for skin conditions. Findings include: During an observation on 5/26/2026 at 10:14 AM Resident #32 was lying in bed PICC [peripherally inserted central catheter] line dressing dated 5/6/2026. There was no redness or swelling at the site. During an interview on 5/26/2026 at 10:14 AM Resident #32 stated she was getting antibiotics for wound infection of a wound in her back which she was admitted with. She was unable to recall when was the last time they change dressing. Resident #32 denied any discomfort with her arm at this time. During an interview on 5/6/2026 at 11:54 AM, Staff C, Licensed Practical Nurse (LPN) stated, IVs [intravenous] dressing are to be changed every 7 days. During an interview on 5/26/2026 at 12:22 PM, Staff C, LPN, confirmed Resident #32's dressing was dated 5/6/2026 and needed to be changed. Review of Resident #32 physician order dated 5/6/2026 read, IV: PICC Line: Change transparent…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to perform hand hygiene to prevent the possible spread of infection during medication administration in 6 of 9 observations of medication administration.Findings include: During an observation of medication administration on 5/27/2026 at 8:04 AM for Resident #111, Staff D. Licensed Practical Nurse (LPN) did not perform hand hygiene, retrieved keys from their uniform pocket, unlocked the medication cart, activated and typed on the computer. Staff D, LPN donned gloves without performing hand hygiene, locked the medication cart, placed keys in pocket, and closed the computer. Staff D. LPN picked up medication cards and a glass of water and the medication cup, placed their thumb in the inside of the medication cup touching the medications and entered the residents room, administered the medications without changing gloves or performing hand hygiene. During an observation of medication administration on 5/27/2026 at 8 :12 AM Staff D, LPN returned to the medication cart and began to prepare medications for Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-17 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews and policy and procedure review, the facility failed to maintain a complete and accurate medical record when it failed to document within the medical record the reason medications were not administered for three of three residents reviewed for medication administration (Residents #7,#9 and #10). Findings include: Review of the admission record for Resident #9 documented an admission date of 5/20/2025 with medical diagnoses that include anxiety disorder unspecified, depression unspecified, essential (primary) hypertension (high blood pressure), unspecified fracture of right pubis (break in the bone of the pelvis) subsequent encounter for fracture with routine healing, fall on same level from slipping tripping and stumbling without subsequent striking against object subsequent encounter, gastroesophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease unspecified. Review of Resident #9's physician orders dated 5/20/2025 read, Alprazolam Oral Tablet 0.5 MG (milligram) Give 1 tablet by mouth in the morning for anxiety.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2025-01-16 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for one resident (Resident #109) of four reviewed for discharge. Findings include: Review of Resident #109's admission record documented the resident was admitted to the facility on [DATE] and discharged on 10/15/24. Diagnoses included pneumonia, sepsis, acute respiratory failure, chronic obstructive pulmonary disease, hypertension and atrial fibrillation. Review of the Minimum Data Set (MDS), Assessment Return Not Anticipated, Section A ,dated 10/21/24 documented Resident #109 was discharged to a hospital. Review of Resident #109's progress notes dated 10/21/24 read, Pt (patient) and family decided that they wanted pt transferred to [Name of Nursing Home] said that was the facility originally chosen for pt however they didn't have any available beds at time of discharge from hospital so, pt decided until a bed became available that she would come to this facility.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure a comprehensive care plan was developed for 4 (Resident #4, 49, 77, and 79) of 10 residents reviewed for oxygen therapy. Findings include: 1) Review of Resident #79's admission record documented an admission date of 5/17/2024 with diagnosis that included heart failure, hypertensive heart disease, and COPD (chronic obstructive pulmonary disease). Review of Resident #79's physician order dated 9/1/2024 read, Oxygen @ 2 L/Min (at 2 liters per minute) via nasal cannula inhalation as needed as needed {sic} for COPD. Review of Resident #79's comprehensive care plan did not document focus for respiratory services. 2) Review of Resident #77's admission record documented an admission date of 11/15/2024 with diagnosis that included acute and chronic respiratory failure with hypercapnia and pneumonia. Review of Resident #77's physician order dated 1/14/2025 read, Oxygen tubing, cannula/mask change weekly and PRN (as needed) every night shift every Sat [Saturday] AND as needed. Review of Resident #77's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to accurately document notifications of medication parameters for 1 (Resident #39) of 6 residents reviewed for medication administration. Findings include: Review of Resident #39's physicians order dated 9/10/24 read, Insulin NPH (Neutral Protamine [NAME]) Isophane & Regular Subcutaneous Suspension (70-30) [70% Isophane and 30% regular or short acting insulin] 100 unit /ml (Insulin NPH Isophane & Reg (Human)) Inject 10 unit subcutaneously in the evening for DM [Diabetes Mellitus] Hold for BG <150 [Blood Glucose less than 150]. Review of Resident #39's Medication Administration Record (MAR) for the month of January 2025 documented Insulin NPH Isophane & Regular Subcutaneous Suspension Insulin was administer on 1/10/2025 at 2100 [9:00PM] when blood glucose level was 126 and on 1/14/2025 at 2100 for a blood glucose level of 123. Review of Resident #39's MAR for the month of December 2024 documented Insulin NPH Isophane & Regular Subcutaneous Suspension was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to follow infection control standards of practice during 1 of 5 medication administration observations and 2 (Resident #4 and #20) of 10 residents reviewed for oxygen therapy. Findings include: 1). During a medication administration observation on 1/15/25 at 8:40 AM for Resident #39, Staff B, Registered Nurse (RN) removed the cap to a vial of Ceftriaxone sodium injection solution 1 gram and removed the cap to a vial of sterile water. Staff B, RN opened a sterile needle with syringe and inserted the needle into the vial of sterile water without wiping the rubber of the vial with an alcohol wipe. Staff B, RN withdrew 2.1 ml [milliliters] of sterile water and inserted the needle of the syringe with sterile water into the vial of Ceftriaxone sodium injection solution 1 gram without wiping the rubber top of the Ceftriaxone vial with an alcohol wipe. Staff B, RN left the needle in the vial of Ceftriaxone and shook the vial. Staff B, RN then attempted to withdraw the solution using the syringe still attached, but…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-01 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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. 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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's representative was notified of a change in condition for 1 of 3 residents, Resident #1. Findings include: Review of the admission Record for Resident #1 documented the resident was admitted on [DATE] with diagnoses to include hypertension, muscle weakness, mild protein calorie malnutrition, diabetes mellitus, dementia and sepsis. Review of laboratory results dated [DATE] documented results that were not within the resident's normal limits and were high for the blood urea nitrogen (BUN), chloride, and the BUN creatinine ratio. Review of the nursing progress note for Resident #1 dated 10/11/2023 at 04:02 AM read. Nurse was called to resident room it was noted that a very small open area to sacrum skin was peeling off. Area cleaned and barrier cream applied will inform MD and family later. Review of nursing progress notes for the period of 10/03/2023 to 11/14/2023 did not contain documentation the resident's representative was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    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. 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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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. 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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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. 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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-05 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-05 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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. 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…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$157,729 in federal fines across 1 penalty.

  • $157,729 — penalty dated 2025-06-17

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SUMMIT CARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 53.3-2.3 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 2 of 52.6-0.6 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 21 homes this chain runs (chain average 3.3★, per CMS)
1 of 5Valencia Hills Health And Rehabilitation CenterLakeland, FL 2 of 5Northbrook Center For Rehabilitation And HealingBrooksville, FL 2 of 5Palatka Center For Rehabilitation And HealingPalatka, FL 2 of 5Scott Lake Health And Rehabilitation CenterLakeland, FL 2 of 5Springs At Boca Ciega BaySouth Pasadena, FL 2 of 5Springs At Lake Pointe WoodsSarasota, FL 3 of 5Lake Bennet Center For Rehabilitation & HealingOcoee, FL 3 of 5Seven Hills Health & Rehabilitation CenterTallahassee, FL 3 of 5Timberridge Nursing & Rehabilitation CenterOcala, FL 3 of 5Ybor City Center For Rehabilitation And HealingTampa, FL 4 of 5Hawthorne Center For Rehabilitation And Healing OfBrandon, FL 4 of 5Lakeside Center For Rehabilitation And HealingJacksonville, FL 4 of 5Sandy Ridge Center For Rehabilitation And HealingMilton, FL 4 of 5Santa Rosa Center For Rehabilitation And HealingMilton, FL 4 of 5Surrey Place Healthcare And RehabilitationBradenton, FL 4 of 5Tampa Lakes Health And Rehabilitation CenterLutz, FL 5 of 5Century Center For Rehabilitation And HealingCentury, FL 5 of 5Diamond Ridge Health And Rehabilitation CenterLecanto, FL 5 of 5Hawthorne Center For Rehab & Healing Of SarasotaSarasota, FL 5 of 5Madison Health And Rehabilitation CenterMadison, FL 5 of 5North Bank Center For Rehabilitation And HealingJacksonville, FL

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
HAWTHORNE OPERATIONS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2021
DREBIN, EZRIELIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2021
HERZKA, YISROELIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2021
KOPELOWITZ, SHAULIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2021
WOLOFSKY, CHAVAIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2021
GONZALES, RAMONAIndividualW-2 MANAGING EMPLOYEEsince 03/09/2022
HAWTHORNE CARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$13.8M
Net patient revenuemost recent cost report
-11.8%
Operating marginrevenue minus expenses
$2.6M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 51%Medicare 16%Other / private 33%

This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$384per resident / day
operating cost
$11,682per month
≈ monthly operating cost
$344per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105602. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next