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F0699
E

Failure to Provide Trauma-Informed Care for Residents with PTSD

Pomona, California Survey Completed on 08-21-2025

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 ensure that two residents with documented diagnoses of Post Traumatic Stress Disorder (PTSD) received care that addressed their individual trauma experiences, as required for trauma-informed and culturally competent care. Both residents were admitted with PTSD and other mental health conditions, and their Minimum Data Set assessments indicated that they were cognitively intact and independent with activities of daily living and mobility. Despite these documented diagnoses, neither resident had a care plan (CP) specifically addressing PTSD. During interviews, a Licensed Vocational Nurse confirmed that care plans should have been created for these residents to address signs and symptoms, maintain well-being, provide coping strategies, and guide staff in delivering consistent care. The absence of PTSD-specific care plans meant that staff did not have guidance to recognize or address the residents' trauma, even if the exact trauma was not disclosed. The Director of Nursing also acknowledged that the facility was responsible for developing care plans tailored to each resident's trauma and unique experiences, and that the lack of such plans meant the residents' trauma-informed needs were not fully addressed. A review of the facility's policy on trauma-informed care indicated that care should be provided in a manner that accounts for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. However, the facility did not implement these policies for the two residents in question, resulting in a deficiency related to the provision of trauma-informed and culturally competent care.

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