Health inspection·May 23, 2025

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to: Residents Affected - Few 1. Ensure a thorough Trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident ' s ability to cope) Care Evaluation was completed for one of four sampled residents (Resident 1). 2. Develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) that addressed past trauma and triggers (something that reminds you of a past traumatic experience and causes a strong emotional reaction, like experiencing the trauma again) for one of four sampled residents (Resident 1). These deficient practices had the potential to result in delayed identification of underlying trauma-related issues, which could compromise resident care, delay appropriate referrals, and negatively impact resident outcomes. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/12/2023 with diagnoses that included complete paraplegia (a complete loss of feeling and movement in both legs), anxiety disorder (mental health condition characterized by persistent and excessive worry, fear, and nervousness that can interfere with daily life) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s psychiatric Intake Note dated 4/3/2025, the Intake Note indicated Resident 1 reported trauma history of being shot in the back leading to his legs being paralyzed. The Intake Note further indicated Resident 1 reported a history of depression secondary to the gunshot injury to his back. During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 5/1/2025, the MDS indicated Resident 1 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was intact. During an interview on 5/22/25 at 1:00 p.m. with Resident 1, Resident 1 stated, I hate when the staff slams my door because loud noises like that are a trigger for me. Resident 1 further stated that he was shot in the back and sudden, loud noises remind him of the loud sound of the gun firing. During a concurrent interview and record review on 5/23/2025 at 3:00 p.m. with the Social Services Director (SSD), Trauma Care Evaluation dated 5/2/25 was reviewed. The Trauma Care Evaluation Page 1 of 2 056412 056412 05/23/2025 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated under question number one (1), the resident declined to participate and questions two (2) through six (6) were left blank. The Trauma Care Evaluation instructions indicated if a resident is not able to participate, contact family members and review the History and Physical (H&P-a comprehensive assessment performed by a healthcare provider to gather information about a patient's medical history and conduct a physical exam) to gain information. The SSD stated the Trauma Care Evaluation was incomplete and more information should have been gathered and documented. The SSD stated gathering and documenting more information about Resident 1 ' s trauma was necessary to help the facility identify the ways Resident 1 ' s past trauma is affecting him now. The SSD stated the information could then help the facility understand Resident 1 ' s trauma in order provide more services and resources to help Resident 1 deal with his past trauma. During a concurrent interview and record review on 5/23/2025 at 3:35 p.m. with the Director of Nursing (DON), Resident 1 ' s care plans from 8/12/2023 to 5/23/2025 were reviewed. The DON stated she could not find a care plan that addressed Resident 1 ' s past trauma and/or potential triggers. The DON stated all staff were aware that Resident 1 experienced trauma in his past and therefore a care plan should have been created to address that trauma. The DON stated having a care plan to address Resident 1 ' s past trauma and potential triggers would help the staff provide appropriate care and treatment for Resident 1 to avoid Resident 1 having to experience any further trauma. During a review of the facility ' s policy and procedure titled, Trauma-Informed and Culturally Competent Care, last revised in March 2023, indicated, it is the policy of the facility to ensure staff provide care that is culturally competent and trauma-informed, as well address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy and procedure also indicated staff is to perform screening of residents for identification of possible exposure to traumatic events and utilize the screening to identify the need for further assessments and care. The policy and procedure further indicated the facility is to develop individualized care plans that address past trauma in collaboration with the resident and family, that identify and decrease exposure to triggers that may re-traumatize the resident. 056412 Page 2 of 2