Hawthorne Healthcare: Mental Health Screening Failure - CA
Federal inspectors cited Hawthorne Healthcare & Wellness Centre, LP during a March 27, 2026 inspection for failing to update a required mental health screening before placing Resident 12 on Haloperidol, a psychotropic medication used to treat mental and mood disorders. The physician had ordered 10 milligrams twice daily, at 9 a.m. and 5 p.m., for schizophrenia manifested by aggressive behavior.
The screening in question, called a PASARR Level 1, had been completed by the facility on March 18, 2021. It recorded that Resident 12 had no serious mental illness diagnoses and was not on any psychotropic medications. It also noted the case was closed, meaning a deeper Level II mental health evaluation was not required.
By the time inspectors arrived, Resident 12 carried diagnoses of paranoid schizophrenia, major depressive disorder, and psychosis, and had been prescribed Haloperidol. None of that had triggered a new screening.
The Director of Nursing acknowledged all of it directly.
During a concurrent interview and record review on March 25, 2026, the Director of Nursing told inspectors that the facility should have completed and resubmitted a new PASARR Level 1 screening under the Resident Review process given the mental illness diagnoses and the new medication. She stated plainly that the facility did not follow that procedure.
The PASARR process, which stands for Preadmission Screening and Resident Review, exists specifically to ensure that nursing home residents with serious mental illness receive appropriate evaluation and, where needed, specialized services. A Level 1 screening is the first step. When a resident's condition changes in ways that suggest serious mental illness, facilities are required to trigger a new review rather than rely on whatever the original admission paperwork said.
In this case, the original paperwork said there was nothing to review. The resident's condition had changed substantially. Nobody updated the paperwork.
The facility's own policy, dated June 2024, assigned responsibility for maintaining and updating PASARR screenings to the MDS coordinator. That policy was in place nearly two years before inspectors found the lapse.
The physician's order for Haloperidol had been placed by telephone on March 23, 2026, three days before inspectors reviewed it. The order summary report confirmed the prescription and its schedule. What it did not reflect was any updated mental health evaluation to accompany the new diagnosis and new drug.
Haloperidol is an antipsychotic with a significant side effect profile. In older adults, it carries particular risks, including movement disorders and sedation. Prescribing it without the required mental health review process in place means the structured evaluation that might otherwise flag concerns, recommend alternatives, or connect a resident to specialized psychiatric services never happened.
The deficiency was rated at minimal harm or potential for actual harm, affecting few residents. That classification sits near the lower end of the federal severity scale. It does not mean the gap carried no risk.
What it means, in practice, is that a resident with three serious mental illness diagnoses was started on an antipsychotic while the facility's official record still described him as someone with no mental illness at all, a record that had not been touched in five years, and that the Director of Nursing, when shown the discrepancy, agreed the facility had simply not done what it was supposed to do.
The screening that should have been updated sat unchanged since 2021. The diagnoses accumulated. The medication was prescribed. The paperwork said nothing had changed.
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.
The physician had ordered 10 milligrams twice daily, at 9 a.m.
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.