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F0656
D

Failure to Timely Develop Trauma-Informed Care Plan After Resident Disclosure

Pomona, California Survey Completed on 08-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop an individualized, person-centered care plan with measurable objectives and timeframes to address a resident's reported history of past trauma. After the resident disclosed a previous rape to the administrator, this information was not promptly incorporated into the resident's care plan. Although a care plan addressing emotional distress related to recent abuse allegations was created, a trauma-informed care plan specific to the resident's history of sexual assault was not initiated on the same day as the disclosure. Interviews with facility staff, including the Social Services Director and Director of Nursing, confirmed that the trauma-related care plan was not developed in a timely manner, despite the recognition that such planning is essential for addressing emotional and psychological needs. The resident, who had diagnoses including heart failure, COPD, and diabetes mellitus, was cognitively intact and required partial to moderate assistance with activities of daily living. The resident reported never having shared the history of sexual assault with the facility prior to the recent abuse allegation involving a staff member. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to meet identified needs. However, the lack of timely trauma-informed care planning resulted in a deficiency in meeting the resident's individualized needs.

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