Failure to Update Trauma Care Plan After Sexual Abuse Report
Summary
The facility failed to ensure one resident was provided a trauma informed plan of care after the resident reported sexual abuse by a peer. The resident was admitted in April 2025 with diagnoses including anxiety disorder, paraplegia, and depression, and the most recent MDS indicated intact cognition with a Brief Interview for Mental Status score of 15 out of 15, no behaviors, and dependence on staff for care and transfers. The resident’s trauma care plan, last updated on 4/28/25, addressed a history of trauma related to an accident and paraplegia, with interventions such as encouraging the resident to identify trauma triggers, verbalize feelings, and providing support for loud noises or aggressive behavior from others. The resident reported that another resident repeatedly made sexually explicit and threatening comments, including an incident in which the other resident approached the resident in the hall and made vulgar sexual statements. The resident stated that the issue had been reported to the facility multiple times, that an email was sent to the DON and NHA, and that police were called. The resident also stated that the other resident’s behavior continued after the police response and that the resident lived in fear because he/she could not protect himself/herself or get up and run. Review of the medical record showed the trauma care plan was not updated after the sexual threats and abuse report to include resident-specific triggers and interventions related to the incident. Interviews with staff confirmed the need for an updated trauma care plan: the CNA said the resident became scared and uncomfortable when hearing the accused resident nearby during care, the SW said the resident should have a trauma care plan addressing support needs, the DON said the plan should have been updated after the incident, and the NHA said safeguards should have been put in place and the trauma care plan updated following the event.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to identify and document trauma triggers in the care plans of two residents with PTSD. One resident with dementia and severe cognitive impairment had a trauma history noted but no triggers listed on the trauma care plan, and no social services re-evaluation was completed after a prior assessment despite the MDS continuing to show PTSD as an active diagnosis. Another resident with depression and PTSD related to Vietnam War service had a trauma evaluation and social services assessment documenting nightmares, difficulty sleeping, and specific triggers of loud noises and enclosed spaces, yet the active trauma care plan only contained vague language and an incomplete intervention to "avoid (specify)" without listing those triggers.
Failure to Individualize Trauma-Informed Care Plans: Three residents with documented trauma histories, including sexual abuse, violent crime exposure, and PTSD from military history, had care plans that listed only general trauma-informed interventions. The DON confirmed the plans did not identify resident-specific triggers or include interventions tailored to avoid those triggers, and one resident’s plan also lacked trauma-specific triggers despite a history of sexual abuse.
A resident with PTSD, dementia, and other diagnoses did not have specific trauma-informed interventions documented in the care plan. The POA reported the PTSD was related to a military assault and said only female caregivers should provide direct care to avoid triggering behaviors, but the chart had no such instruction. The DON and Social Services Director were unaware of the resident’s PTSD triggers, and a male CNA was observed providing personal care without knowledge of the resident’s request for female staff.
The facility failed to provide trauma-informed care by not consistently identifying, documenting, or care-planning for PTSD-related triggers in three residents with PTSD. One resident with dementia and PTSD had known behavioral symptoms and a known trigger related to male caregivers, acknowledged by an LPN, but this trigger and related interventions were not included in the care plan. Another resident admitted with a documented PTSD diagnosis from a VA source had PTSD incorrectly marked as absent on the trauma-informed care assessment, with no trauma history, triggers, or individualized interventions documented by social services. A third resident with PTSD, depression, anxiety, insomnia, and quadriplegia had general psychosocial interventions in the care plan, but repeated social service notes stated no triggers were identified, despite later reports of worsening depression, nightmares, and poor sleep; staff, including an LPN and the DON, confirmed that PTSD triggers were neither identified nor incorporated into the care plan.
The facility did not identify PTSD triggers in the care plan for a resident with a known PTSD diagnosis and failed to assess another resident for PTSD despite recent traumatic experiences. Two residents were affected, and the facility's policy requiring trauma-informed care and identification of triggers was not followed.
A resident with dementia and PTSD, who had a history of traumatic experiences and behavioral symptoms, did not receive trauma-informed care as required. The care plan, Kardex, and nursing notes lacked references to trauma or related interventions, and staff were unaware of specific trauma triggers or care needs. Facility policy required trauma assessments and care planning, but these were not completed or reflected in the resident's documentation.
Failure to Identify and Document PTSD Trauma Triggers in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed care by identifying and documenting trauma triggers on care plans for residents with PTSD, as required by regulation and facility policy. For one resident with Alzheimer’s disease, dementia, major depressive disorder, PTSD, and severe cognitive impairment, the trauma care plan initiated in mid-2023 noted a past abusive relationship as a trauma history but did not identify any specific trauma triggers. Social services re-evaluations completed in 2025 repeatedly documented that the resident had not suffered from PTSD since the last assessment, but there was no subsequent social services re-evaluation after November 2025 despite the quarterly MDS in January 2026 listing PTSD as an active diagnosis. The social services worker confirmed that no triggers were identified on the care plan and there was no documentation that the resident denied having triggers, and also confirmed the absence of a required re-evaluation after November 2025. For a second resident admitted in early 2026 with major depressive disorder and later-documented PTSD, the facility completed a trauma evaluation that recorded affirmative responses to questions about experiencing a frightening or traumatic event and having unwanted thoughts or nightmares about it, but the form did not explain what the resulting score meant and contained no additional comments. The resident was hospitalized for pneumonia and, during that hospitalization, PTSD was listed as an active diagnosis treated with Effexor. Upon readmission, the attending physician and a subsequent social services re-evaluation both documented PTSD as an active diagnosis, with the social services assessment specifying that the PTSD was related to Vietnam War service, that the resident had difficulty sleeping almost every night, and that loud noises and closed spaces were identified as triggers. Despite this information, the resident’s active trauma care plan only generally stated that he had experienced trauma in the past, that his PTSD was from the Vietnam War, and that he was followed by VA psychiatric services. The care plan described possible trauma expressions such as hypervigilance, social isolation, and flashbacks, and included goals related to feeling safe and not being re-traumatized, but the interventions section merely stated to avoid “(specify)” without listing the known triggers. During an interview, the resident confirmed that loud or sudden noises and enclosed spaces were triggers and described his reaction when triggered, yet these specific triggers were not incorporated into the trauma-informed care plan until the day of the survey, contrary to the facility’s policy requiring that identified trauma and triggers be addressed in the care plan and that social services re-evaluations be completed with each MDS or at least every 90 days.
Plan Of Correction
1. On 4/14/26 the Social Service Designee reviewed resident #78's Trauma Care Plan and updated it to indicate no identified triggers for PTSD. A social service re-evaluation was completed on 4/24/26 by the Social Service Director at which time the resident denied any trauma. On 4/28/26 the Social Service Designee reviewed resident #109's Trauma Care Plan and updated it to include identified triggers for PTSD. 2. Like Residents are identified as residents who have a history of trauma. Utilizing the Trauma Informed Care Audit Tool, which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Social Services Designee to ensure the SS evaluation accurately identifies PTSD and they have identified trauma triggers listed on their trauma care plan. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Administrator or designee will re-educate the Social Services department on the Social Services Documentation Policy to include evaluating trauma and care planning triggers for residents with a history of trauma. This education will be completed on or before 5/13/26. 4. Utilizing the Trauma Informed Care Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit admissions, readmissions and residents due for quarterly assessments weekly for four weeks beginning 5/14/26 to ensure the SS evaluation identifies those with PTSD diagnosis and that trauma triggers are listed on their trauma care plan. Noncompliance noted from audits will be corrected with residents reassessed and care plans revised as indicated. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Individualize Trauma-Informed Care Plans
Penalty
Summary
The facility failed to ensure resident-specific interventions were implemented to address residents’ histories of trauma for three residents reviewed for trauma-informed care. For one resident with diagnoses including dementia, bipolar disorder, and depression, the care plan identified trauma related to sexual abuse and included general interventions such as reassurance, comfort measures, social interaction, and referral to psychiatric or counseling services, but the DON, an LPN, and the Social Service Director confirmed the care plan did not include trauma-specific triggers or interventions to address or avoid those triggers. For another resident with diagnoses including morbid obesity, neuromuscular dysfunction of the bladder, and a right femur neck fracture, the care plan identified a history of trauma related to being in a situation/environment and being a victim of a violent crime, but the documented interventions were general and did not identify any trauma triggers. For a third resident with diagnoses including an unspecified head injury, PTSD, and psychophysiologic insomnia, the care plan addressed trauma-related PTSD from military history with general interventions such as building trust, observing for anxiety, decreasing environmental stimulation, and providing reassurance, but it contained no resident-specific PTSD triggers. The DON verified that the care plans for these residents did not contain specific triggers and that the interventions were not resident-specific.
Failure to Document and Provide PTSD Trigger-Based Care
Penalty
Summary
The facility failed to ensure trauma-informed and culturally competent care for a resident with PTSD. Resident #10 was admitted with diagnoses including dementia, neurocognitive disorder with Lewy bodies, depression, and PTSD. The medical record showed a social history and assessment completed by Social Services that listed PTSD, but there was no additional documentation describing the cause or treatment of the PTSD. The social services plan of care addressed mood problems related to cognitive impairment, hallucinations, unspecified PTSD, major depressive disorder, and anxiety disorder, but it did not document specific PTSD triggers, causes, behaviors, or interventions. The resident’s POA stated that the resident’s PTSD was related to an assault while serving in the military and that staff had previously been informed that only female caregivers should provide direct care because male caregivers could trigger behaviors. The medical record contained no documentation directing caregivers to be female. The DON verified there was no knowledge of the resident’s PTSD trigger related to male assault in the military and confirmed the resident had previously received care from male caregivers. Social Services also stated they were unaware of the cause of the PTSD or any potential triggers and verified that no specific PTSD assessment or plan of care had been completed. During observation, a male CNA was providing morning personal care to the resident and stated he was unaware of any request for female direct care staff or PTSD-related care.
Failure to Provide Trauma-Informed Care and Identify PTSD Triggers
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed care by identifying and addressing trauma-related triggers for residents with PTSD, as required by its own policies and care planning processes. For one resident with PTSD and dementia, the MDS and social service assessments documented behavioral symptoms such as verbal and physical behaviors toward others, rejection of care, and socially inappropriate behaviors, as well as identified triggers like distress when others "mess with my stuff" and calming strategies such as talking things out and preferred activities. An LPN reported that male staff were a known trigger for this resident and that staff attempted to limit male caregivers and use redirection when the resident became upset. However, the comprehensive care plan, while listing PTSD as a diagnosis, did not include male caregivers as a trauma-related trigger or any trigger-specific, trauma-informed interventions or staff approaches related to this known trigger, contrary to the facility’s Comprehensive Care Plans policy. For another resident, admission documentation from a Veterans Affairs facility identified PTSD as a diagnosis, and the care plan referenced impaired mood and psychiatric status related to PTSD. Despite this, the facility’s Trauma-Informed Care assessment incorrectly marked PTSD as "No," and social services assessments did not identify PTSD or document any trauma history. The medical record lacked evidence that trauma-related triggers were assessed or identified, and there were no individualized trauma-informed interventions implemented. The Social Services Director stated that when a resident has a PTSD diagnosis, the expectation is that trauma history and PTSD-related triggers are assessed, documented, and communicated to the interdisciplinary team, as required by the facility’s Trauma-Informed Care policy, but this had not occurred for this resident. A third resident had a long-standing diagnosis of PTSD along with quadriplegia, reduced mobility, insomnia, generalized anxiety, major depressive disorder, and chronic pain syndrome. The care plan identified risk for impaired mood and psychiatric status related to depression, PTSD, and anxiety, with general psychosocial interventions such as discussing solutions to conflict, observing for mood changes, and encouraging expression of feelings. Social service progress reviews over several months documented that the resident had PTSD, reported symptoms were being managed effectively, and that the facility had not identified any known triggers. A mental health visit later documented chronic PTSD with increased depression, poor sleep, and nightmares, and an antidepressant was ordered for insomnia. In a subsequent interview, the resident reported PTSD was poorly managed, with persistent night terrors and significantly reduced sleep, and expressed interest in working with social services to manage PTSD and identify possible triggers. The Social Services Director confirmed there were no documented triggers in the social service notes or care plan, and an LPN was unaware of any PTSD triggers for this resident, while the DON acknowledged that PTSD diagnoses should have triggers identified and monitored in the care plan. This series of omissions demonstrated the facility’s failure to identify and document trauma-related triggers and integrate them into care planning for residents with PTSD.
Failure to Identify and Address PTSD Triggers and Assess for Trauma
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with significant histories of trauma and mental health concerns. For one resident with diagnoses including PTSD, anxiety disorder, and depression, the care plan did not include specific PTSD triggers, despite documentation in the social services evaluation that identified triggers such as people, thoughts, and feelings. The care plan only addressed general interventions for mood and anxiety but omitted the individualized triggers that could help staff avoid re-traumatization. This omission was confirmed by the social worker during an interview. For another resident with a history of recent traumatic events, including the loss of a child to suicide and a recent bilateral leg amputation, there was no assessment for PTSD upon admission or during the resident's stay. The resident expressed feelings of sadness and depression and requested to speak with someone, but the social service designee was unaware of the resident's traumatic loss and confirmed that no PTSD assessment had been completed. The facility's policy requires trauma to be identified and addressed in the care plan, including triggers and interventions, but this was not done for these residents.
Failure to Provide Trauma-Informed Care for Resident with PTSD and Dementia
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of dementia, major depressive disorder, anxiety disorder, intermittent explosive disorder, alcohol abuse, and post-traumatic stress disorder (PTSD). The resident had documented traumatic experiences, including being assaulted and serving in the Vietnam War, which were noted in psychosocial assessments and family interviews. Despite these documented traumas and ongoing behavioral symptoms such as paranoia, hallucinations, resistance to care, and combativeness, there was no evidence that trauma-specific assessments were completed after admission. The resident's care plan, last reviewed in April 2025, did not reference trauma, trauma triggers, or trauma-informed interventions, even though the resident was dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits. The Kardex for nursing assistants and nursing progress notes from June 2024 to June 2025 also lacked any information or documentation relevant to trauma or trauma-informed care. Staff interviews confirmed a lack of knowledge regarding specific trauma-related care or triggers for the resident, and the social services staff reported that no specific trauma assessment was used beyond an initial screening at admission. The facility's policy required assessment and care planning for trauma and behavioral health issues on admission and quarterly, including identification of triggers and non-pharmacological interventions. However, the care plan and supporting documentation did not reflect these requirements for the resident in question, and staff were not able to identify or implement trauma-informed care practices as outlined in the policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
