F0699

D

Failure to Provide Trauma-Informed Care for Identified Trauma Survivors

Canonsburg, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to provide trauma-informed care to residents identified as trauma survivors, as required by its policy "Trauma Informed Care and Culturally Competent Care" dated 8/27/25. This policy states that the purpose is to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Resident R7’s admission record showed admission to the facility and a Minimum Data Set (MDS) dated 11/10/25 documented diagnoses of PTSD, dementia, and high blood pressure, with Section I6100 indicating PTSD is present. Resident R7’s current care plan noted use of psychotropic medications related to vascular dementia and PTSD, but the care plan did not include a trauma-informed care plan addressing PTSD or identifying potential triggers and strategies to prevent re-traumatization. The DON confirmed that the care plan lacked a trauma-informed component addressing PTSD and triggers.

Resident R33’s admission record showed admission to the facility and an MDS documenting diagnoses of anemia, heart failure, and high blood pressure. During an interview, Resident R33’s legal guardian reported that the resident had a history of being victimized by predators involving cellular phone usage, indicating a past trauma. Review of Resident R33’s care plan and clinical record did not identify this traumatic history. The DON stated that the facility was unaware of this trauma history and did not have a trauma-informed care plan in place to address it or to identify potential triggers and prevention for re-traumatization. The Nursing Home Administrator confirmed that the facility failed to provide trauma survivors with trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization for two of four residents reviewed (R7 and R33).