F0699

D

Failure to Complete Trauma-Informed Assessment After Alleged Resident-to-Resident Assault

Baltimore, Maryland Survey Completed on 02-24-2026

Penalty

Fine: $55,890

Summary

Surveyors found that the facility failed to provide trauma-informed care by not completing a trauma-informed assessment or care plan for a resident who experienced an alleged physical assault by another resident. A complaint reported that Resident #5 alleged another resident entered the room in the evening, grabbed both of the resident’s hands, and punched the resident in the face approximately five times. Record review showed that after this incident there was no documentation that a trauma-informed assessment had been conducted or that a trauma-informed care plan had been developed to address the resident’s trauma history or needs following the event.

During an interview, Resident #5 was tearful and reported being in fear, afraid to go to sleep at night, and scared when the alleged perpetrator walked into the dining room. Interviews with facility leadership confirmed that trauma-informed assessments were expected to be completed at admission and after a change in condition, but this had not been done for Resident #5 following the reported assault.