The breakdown in communication at Lacamas Creek Post Acute left the cognitively intact resident without trauma-informed care integrated into their treatment plan. Federal inspectors found the facility failed to coordinate mental health services properly, putting the resident at risk of re-traumatization and diminished quality of life.
The resident was admitted in September for rehabilitation following hospitalization. A pre-admission screening dated September 24 indicated they should have been evaluated for mental health services based on a mood disorder. The quarterly assessment tool confirmed the resident was cognitively intact.
A mental health assessment documented the resident's history of trauma from adolescence into adulthood. Yet when inspectors interviewed facility staff in November, none of the key personnel knew about it.
Staff C, the Social Services Director, told inspectors on November 25 she was not aware of any history of trauma for the resident. She assumed the psychology provider would inform the facility if concerns arose during mental health sessions. "She was unsure how the communication occurs for mental health service coordination," inspectors wrote. Staff C said the Resident Care Managers would likely be notified directly.
Sixteen minutes later, inspectors interviewed Staff D, a registered nurse and Resident Care Manager. Staff D also said they were not aware of the resident's trauma history. The mental health provider meets with care managers directly before seeing patients on each visit, Staff D explained, but "she was not aware of how information would be shared if discussed by mental health."
Staff D was not aware of concerns with suicidality or childhood trauma for the resident.
The Director of Nursing, Staff B, told inspectors the same thing. Staff B was not aware of the resident's trauma or mental health notes regarding suicidality. "She was not sure how the MH provider communicates with the facility to ensure concerns were included in the residents' care plan," according to the inspection report.
The facility's own policy, dated August 2022, defines trauma-informed care as "an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma." The policy states that trauma-informed care "recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization."
None of that happened.
Inspectors found no care plan for trauma-informed care in the resident's electronic health record. The communication gap meant the resident received standard rehabilitation services without the specialized approach their documented trauma history required.
Federal regulations require nursing homes to provide trauma-informed care that recognizes and responds to the effects of all types of trauma. The approach is designed to avoid re-traumatizing residents who have experienced abuse, neglect, or other harmful events earlier in their lives.
Research shows that trauma survivors often experience heightened stress responses to medical procedures, unfamiliar environments, and loss of control over their daily routines. Without proper trauma-informed care, nursing home residents with trauma histories can experience flashbacks, increased anxiety, and deteriorating mental health.
The inspection found that despite having a psychology provider who conducted mental health assessments and met regularly with care managers, critical information about the resident's trauma history never made it into their care plan. The facility's communication system between mental health services and nursing staff had failed completely.
The resident's case illustrates a broader problem in nursing home care coordination. Mental health providers often work as contractors, creating potential gaps in communication with facility staff who develop and implement daily care plans. When those gaps occur, residents with complex mental health needs may not receive appropriate therapeutic interventions.
The facility received a citation for failing to provide trauma-informed care, with inspectors noting the violation placed residents at risk of not receiving mental health interventions that therapeutically support them. The inspection was conducted on December 22 following a complaint.
For this resident, the consequences remain unclear. They continue to receive rehabilitation services at a facility where key staff members remain unaware of their documented history of trauma from adolescence into adulthood.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lacamas Creek Post Acute from 2025-12-22 including all violations, facility responses, and corrective action plans.