Hawthorne Healthcare: Communication Board Denied to Stroke Patient - CA
Inspectors from the Centers for Medicare and Medicaid Services visited Hawthorne Healthcare & Wellness Centre in late March 2026 and found Resident 58 lying in her room without the tool her care team had documented she needed. The care plan, dated May 2, 2022, listed it explicitly: evaluate the resident's ability to use a communication board, use alternative communication tools as needed. Nearly four years later, there was no board at her bedside.
The resident had been admitted to the facility, then readmitted, with a list of diagnoses that made clear how much she depended on others to understand her. Aphasia, the disorder that took her ability to speak. A cerebral infarction, the stroke that caused it. Type 2 diabetes, which complicates wound healing and requires close monitoring. Osteoporosis. She was cognitively intact, according to a federally mandated assessment completed in January 2026. She understood what was happening around her. She simply could not say so.
At 3:23 p.m. on March 25, inspectors stood in her room and watched her try to communicate through gestures. There was no writing pad. No picture board. Nothing her care plan had promised her.
The next morning, a facility MDS nurse identified in the report as MDSN 2 sat down with inspectors and confirmed what they had already seen. Nonverbal residents, the nurse said, are supposed to receive a communication board with pictures so they can point to what they need, or a marker so they can write. Resident 58 had neither. "Resident 58 was not provided a communication board," MDSN 2 told inspectors. "Resident 58 used gestures to indicate her needs."
The nurse did not minimize what that meant. The risk of relying on gestures instead of a board, MDSN 2 said, was that staff could misread what the resident was trying to express, or fail to understand her at all. Her needs could go unmet not because nobody asked, but because nobody could be sure of the answer.
The facility's own written policy, updated as recently as February 24, 2026, one month before inspectors arrived, listed communication boards and writing pads as examples of adaptive devices staff may provide to residents. The policy existed. The care plan existed. The need was documented, assessed, and acknowledged by staff on the record. The board did not exist.
CMS classified the violation at the lowest level of harm, describing it as having the potential for actual harm rather than documented harm already done. That classification reflects what inspectors could prove, not necessarily what the resident experienced during the years her care plan went unfulfilled.
What is documented is this: a woman who is cognitively intact, who understands the world around her and has things she wants to communicate, has been navigating daily life in a nursing home by gesturing at staff and waiting to see if they got it right. Her care plan recognized that was not good enough in 2022. The facility had not fixed it by March 2026.
MDSN 2 put it plainly. The care plan indicated Resident 58 should have had a communication board, the nurse said, "instead of having staff translate her needs."
Nobody had given her one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hawthorne Healthcare & Wellness Centre, Lp from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP in HAWTHORNE, CA was cited for violations during a health inspection on March 27, 2026.
Nearly four years later, there was no board at her bedside.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.