Cycle 1
Health 2024-03-13 · Fire 2024-03-13
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Brandon, FL
Hawthorne Center For Rehabilitation And Healing Of
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
851 West Lumsden Rd, Brandon, FL
(813) 661-8998
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
121
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinite Care
Operator or chain grouping
Approved since
1995-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.81
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,407
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.57
Baseline 24.96% · Performance 21.73% · Measure score 3.57 · Achievement 0 · Improvement 3.57
Healthcare-associated infections
4.2
Baseline 8.08% · Performance 6.63% · Measure score 4.2 · Achievement 4.02 · Improvement 4.2
Total nurse turnover
5.42
Baseline 61.59% · Performance 41.52% · Measure score 5.42 · Achievement 5.42 · Improvement 4.96
Adjusted total nurse staffing
0
Baseline 3.61 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.2% |
10.72%
2.5 pts worse
|
Worse than the National Rate · Eligible stays 567 · Observed rate 13.58% · Lower 95% interval 10.77% |
| Discharge to community | 46.08% |
50.57%
4.5 pts worse
|
No Different than the National Rate · Eligible stays 555 · Observed rate 40.36% · Lower 95% interval 41.55% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.77% |
95.27%
4.5 pts better
|
Numerator 435 · Denominator 436 |
| Falls with major injury | 1.38% |
0.77%
0.6 pts worse
|
Numerator 6 · Denominator 436 |
| Discharge self-care score | 70.98% |
53.69%
17.3 pts better
|
Numerator 203 · Denominator 286 |
| Discharge mobility score | 68.53% |
50.94%
17.6 pts better
|
Numerator 196 · Denominator 286 |
| Pressure ulcers or injuries, new or worsened | 3.9% |
2.29%
1.6 pts worse
|
Numerator 17 · Denominator 436 · Adjusted rate 3.32% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 391 · Observed rate 6.39% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 232 |
| Staff flu vaccination coverage | 39.5% |
42%
2.5 pts worse
|
Numerator 94 · Denominator 238 |
| Discharge function score | 74.83% |
56.45%
18.4 pts better
|
Numerator 214 · Denominator 286 |
| Transfer of health information to provider | 87.29% |
95.95%
8.7 pts worse
|
Numerator 254 · Denominator 291 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 86 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 14.59% |
25.2%
10.6 pts worse
|
Numerator 34 · Denominator 233 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
2.6%
1.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.9% · Q3 6.2% · Q4 4.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
3.7%
1.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 3.9% · Q4 3.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
5.9%
3.4 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 9.2% · Q3 6.3% · Q4 4.9% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.7% |
15.7%
6 pts better
|
19.6%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 10.6% · Q3 4.5% · Q4 11.1% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
9.8%
3.3 pts better
|
16.7%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.5% · Q3 11.1% · Q4 3.9% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.7% |
11.7%
2 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
9.8%
4.3 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.8% · Q3 6.2% · Q4 3.4% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.2% |
12.5%
7.3 pts better
|
19.8%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 7.5% · Q3 2.7% · Q4 3.1% · 4Q avg 5.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.1%
0.8 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.2% · Q3 4.5% · Q4 4.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
94.3%
3.1 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 97.7% · Q3 100.0% · Q4 99.3% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
9.3%
3.4 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 5.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.7% · Q3 1.2% · Q4 1.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
94.7%
1.6 pts worse
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
26.2%
0.2 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 24.7% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-10 · Fire 2021-12-10
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-09-25 · Fire 2020-09-25
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-03-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-12
D · Potential for more than minimal harm
2020-09-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-10-17
D · Potential for more than minimal harm
2020-09-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-10-17
D · Potential for more than minimal harm
2020-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-10-17
D · Potential for more than minimal harm
2020-09-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-12-31
D · Potential for more than minimal harm
2020-09-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-10-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-03-13
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-01-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-03
E · Potential for more than minimal harm
2021-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-10
D · Potential for more than minimal harm
2021-12-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-01-10
D · Potential for more than minimal harm
2021-12-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-01-10
D · Potential for more than minimal harm
2021-12-10
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-01-10
L · Immediate jeopardy
2020-09-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-12-14
J · Immediate jeopardy
2020-09-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-12-14
D · Potential for more than minimal harm
2020-09-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-12-14
Penalties and ownership
What sits behind the stars
Ownership
Hawthorne Brandon SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Hawthorne Care Management LLC
Operational/Managerial Control · Organization
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Klein, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Kopelowitz, Shaul
5% Or Greater Indirect Ownership Interest · Individual
Stanton, Susan
W-2 Managing Employee · Individual
Wolofsky, Chava
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
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Aviata At Central Park
Brandon, FL
2-star overall rating with 2-star inspections with $7,456 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Aviata At Oakfield
Brandon, FL
2-star overall rating with 1-star inspections with $43,222 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Victoria Crossing Rehabilitation Center
Brandon, FL
0-star overall rating with 0-star inspections
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