Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hawthorne Center For Rehabilitation And Healing Of during CMS and state inspections, most recent first.
Several residents with a history of Alprazolam use missed multiple doses of their prescribed medication because staff did not know the medication was available in the automated dispensing system and failed to notify the physician or document the missed doses. This resulted in withdrawal symptoms for at least one resident and demonstrated a breakdown in medication administration and communication procedures.
Facility staff failed to administer prescribed Alprazolam to three residents as ordered, resulting in multiple missed doses and withdrawal symptoms for one resident. LPNs were unaware that the medication was available in the automated dispensing system and did not notify providers when medications were unavailable. The DON and Administrator acknowledged gaps in staff training and oversight, and there was no documentation of physician notification or intervention regarding the missed doses.
Three residents with complex medical histories did not receive prescribed Alprazolam for anxiety on multiple occasions, and staff failed to document the reasons for non-administration or notify the physician as required by facility policy. MARs indicated a need for explanatory notes, but no such documentation was found in the residents' records, resulting in incomplete and inaccurate medical records.
A facility failed to ensure an accurate assessment for a resident who was documented as discharged to a hospital, while progress notes indicated a transfer to another nursing home. The MDS Director confirmed the assessment was inaccurate, as the resident was transferred to a skilled nursing facility, not a hospital.
The facility failed to develop comprehensive care plans for residents requiring oxygen therapy, as evidenced by the lack of documented respiratory services focus in the care plans of four residents. A resident with heart failure and COPD had a physician's order for oxygen therapy, but their care plan did not include a focus on respiratory services. Similarly, another resident with respiratory failure and pneumonia had multiple physician orders for oxygen therapy, yet their care plan also lacked a focus on respiratory services. Additionally, the facility did not address the issue of residents self-adjusting their oxygen concentrator settings in their care plans, despite staff acknowledging this behavior.
A facility failed to document medication parameters and provider conversations for a resident. Insulin was administered despite blood glucose levels being below the prescribed threshold, and Midodrine was given when systolic blood pressure was above the limit. Staff followed provider instructions but did not document these interactions, violating the facility's documentation policy.
The facility failed to follow infection control standards during medication administration and oxygen therapy. An RN did not use alcohol wipes on vial stoppers before needle insertion, and two residents had unbagged nebulizer masks on bedside tables, contrary to facility policy. The DON confirmed these practices were not in line with infection control guidelines.
Failure to Administer Prescribed Controlled Medications Due to Staff Unawareness and Communication Breakdown
Penalty
Summary
The facility failed to ensure that residents with prescribed controlled medications, specifically Alprazolam, were administered their medications according to physician orders. Three residents with a history of Alprazolam use experienced multiple missed doses upon admission or during their stay. In each case, staff did not contact the physician when prescriptions were needed, and the medication was not administered as ordered. For example, one resident missed nine doses over several days, resulting in withdrawal symptoms such as sweating, shaking, insomnia, and increased pain. Another resident missed three doses, and a third resident, a long-term facility resident, also missed three doses of Alprazolam. The investigation revealed that staff were unaware that Alprazolam was available in the facility's automated medication dispensing system. Multiple interviews with LPNs and the DON confirmed that nurses did not know they could access the medication from the dispensing system and did not notify the physician or document the missed doses as required. Progress notes for the affected residents did not include any documentation of the missed medication or physician notification. Staff interviews indicated a lack of training and awareness regarding the availability of controlled substances in the dispensing system and the proper procedures to follow when medications were unavailable. The facility's policy required that if a medication with a current, active order could not be located, staff should search all possible locations, contact the pharmacy, or remove the medication from the emergency kit. If a dose of a vital medication was withheld, refused, or not available, the physician was to be notified, and the notification documented. However, these procedures were not followed, and the lack of communication and documentation led to residents not receiving their prescribed medications, resulting in adverse symptoms for at least one resident.
Failure to Administer Prescribed Controlled Medications Due to Policy and Communication Breakdowns
Penalty
Summary
Facility administration failed to implement and enforce policies and procedures for medication administration, resulting in residents not receiving prescribed controlled medications, specifically Alprazolam, as ordered by their physicians. Three residents with histories of Alprazolam use were affected: one was admitted with a prescription for Alprazolam four times daily but experienced a delay of nine missed doses, leading to withdrawal symptoms such as sweating, shaking, insomnia, and increased pain. Another resident, prescribed Alprazolam once daily, did not receive the medication for three days after admission, and a third long-term resident missed three doses of their twice-daily Alprazolam prescription. In each case, there was no documentation of physician notification regarding the unavailability of the medication, and progress notes did not reflect any communication or intervention related to the missed doses. Interviews with nursing staff revealed a lack of awareness about the availability of Alprazolam in the facility's automated medication dispensing system. Several LPNs stated they were unaware that the medication could be accessed from the system and did not know the procedures for obtaining it in the absence of a pharmacy delivery. Staff also failed to notify physicians or nurse practitioners when medications could not be administered, as required by professional standards and facility policy. The DON acknowledged that staff should have called the provider and documented the situation but confirmed that this was not done. The facility's policy required staff to search for medications, contact the pharmacy, and notify the physician if a vital medication was unavailable, but these steps were not followed. The deficiency was further compounded by inadequate staff training and oversight. The DON and Administrator admitted that staff were not properly oriented to the medication distribution system, and there was no regular auditing of medication administration or staff competency regarding the use of the automated dispensing system. The Medical Director and pharmacist confirmed that Alprazolam was available in the emergency drug kit and could have been administered if staff had followed proper procedures. The lack of communication, documentation, and adherence to policy resulted in residents experiencing unnecessary discomfort and withdrawal symptoms due to missed doses of essential medication.
Failure to Document Reasons for Missed Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting the reasons why prescribed medications were not administered. For each resident, Alprazolam was ordered by the physician to address anxiety, but the medication was not given on multiple occasions. The Medication Administration Record (MAR) indicated a chart code requiring further explanation in the nurses' notes, but no such documentation was found in the progress notes for any of the residents. Additionally, there was no evidence that the physician was notified about the unavailability of the medication. Resident #9, with multiple diagnoses including anxiety disorder, depression, hypertension, and chronic obstructive pulmonary disease, did not receive Alprazolam as ordered on several days. Staff interviews confirmed that the medication was not available and that staff did not document the reason for non-administration or notify the physician. Similarly, Resident #10, who had chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder, also did not receive Alprazolam as ordered, and staff again failed to document the reason or notify the physician. Resident #7, with a complex medical history including multiple fractures, chronic heart failure, and anxiety disorder, experienced the same issue, with multiple missed doses of Alprazolam and no corresponding documentation or physician notification. The facility's policy required that any withheld, refused, or unavailable medication be documented in the nurses' notes with an explanatory note and that the physician be notified, with the notification and response documented. Despite this policy, staff interviews and record reviews confirmed that these steps were not followed for the three residents, resulting in incomplete and inaccurate medical records regarding medication administration.
Inaccurate Assessment of Resident Discharge
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident who was reviewed for discharge. The resident, who had been admitted with diagnoses including pneumonia, sepsis, acute respiratory failure, chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, was documented in the Minimum Data Set (MDS) as being discharged to a hospital. However, progress notes indicated that the resident and their family had decided on a transfer to another nursing home, which was the originally preferred facility but had no available beds at the time of the initial discharge from the hospital. Once a bed became available, the resident was transferred to the chosen nursing home, and all necessary documentation was sent. The MDS Director confirmed that the assessment was inaccurate as the resident was transferred to a skilled nursing facility, not a hospital.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop comprehensive care plans for residents requiring oxygen therapy, as evidenced by the lack of documented respiratory services focus in the care plans of four residents. Resident #79, diagnosed with heart failure, hypertensive heart disease, and COPD, had a physician's order for oxygen therapy, but their care plan did not include a focus on respiratory services. Similarly, Resident #77, with acute and chronic respiratory failure and pneumonia, had multiple physician orders for oxygen therapy, yet their care plan also lacked a focus on respiratory services. Interviews with staff confirmed the absence of respiratory focus in the care plans, despite the presence of oxygen orders. Additionally, the facility did not address the issue of residents self-adjusting their oxygen concentrator settings in their care plans. Resident #4's oxygen concentrator settings were observed to be inconsistent with the physician's order, and staff acknowledged that residents sometimes change their settings. However, this behavior was not documented in the care plan. Similarly, Resident #49's oxygen concentrator settings were frequently changed by the resident, but this was not reflected in their care plan. Interviews with staff, including the Director of Nursing and MDS Coordinator, revealed a lack of awareness and documentation regarding residents manipulating their oxygen settings, indicating a failure to revise care plans to address this behavior.
Failure to Document Medication Parameters and Provider Conversations
Penalty
Summary
The facility failed to accurately document notifications of medication parameters for a resident reviewed for medication administration. The resident had a physician's order for Insulin NPH Isophane & Regular Subcutaneous Suspension to be held if blood glucose was less than 150. However, the Medication Administration Record (MAR) showed that the insulin was administered multiple times in December 2024 and January 2025 when the resident's blood glucose levels were below 150. Additionally, the resident had a physician's order for Midodrine to be held if systolic blood pressure was greater than 135, but the MAR documented administration of the medication on several occasions when the resident's systolic blood pressure exceeded this threshold. Interviews with the attending provider and the Director of Nursing revealed that while the staff contacted the provider and acted according to instructions, they failed to document these conversations. The facility's policy on documentation required clinical staff to document the provision of care and services according to nursing standards and regulatory requirements, ensuring that appropriate information is available to all interdisciplinary team members. The lack of documentation of provider conversations and adherence to medication parameters led to the deficiency in maintaining accurate medical records for the resident.
Infection Control Lapses in Medication Administration and Oxygen Therapy
Penalty
Summary
The facility failed to adhere to infection control standards during a medication administration observation involving a registered nurse (RN) and a resident. The RN did not follow proper aseptic techniques when preparing a Ceftriaxone sodium injection. Specifically, the RN did not wipe the rubber stoppers of the vials with an alcohol wipe before inserting a needle, which is a standard practice to prevent contamination. Despite the RN's belief that the vial tops were clean upon cap removal, this practice contradicts established guidelines, as confirmed by the Director of Nursing (DON) and the National Library of Medicine's safety practices for injections. Additionally, the facility did not comply with infection control protocols for oxygen therapy equipment for two residents. Observations revealed that nebulizer masks were left unbagged on bedside tables, contrary to the facility's policy, which requires such equipment to be stored in a plastic bag when not in use. The DON acknowledged that the nebulizer masks should not have been left exposed, as this practice increases the risk of nosocomial infections. These lapses in infection control practices were identified during observations and interviews with facility staff.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Ocala | 0.2 mi | — | 8 | 0 |
| Palm Garden Of Ocala | 0.6 mi | — | 1 | 0 |
| Avante At Ocala, Inc | 2.7 mi | — | 1 | 0 |
| The Lodge Healthcare And Rehabilitation Center | 3.2 mi | — | 0 | 0 |
| Ocala Health And Rehabilitation Center | 3.3 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.