The woman had been admitted to Shoreline Healthcare Center in March after hospitalization for injuries from physical abuse by the family member, identified in records as FM 4. Adult Protective Services and police had already been notified of the abuse by the hospital before her nursing home admission.
Her medical records showed years of verbal, emotional, financial, and physical abuse by FM 4, with multiple police reports filed. She had always taken him back until the incident that led to her recent hospitalization, when she decided to press charges and not return to their apartment.
The facility's interdisciplinary team documented that the resident expressed she did not want any calls or visits from FM 4, felt threatened by him, and should be banned from calling or visiting her. Staff were notified of her wishes after the first incident.
On March 18, FM 4 arrived at the facility to visit the resident. When the case manager informed him of the resident's wishes, he became agitated, used profanity, and said "that is a lie! I was just there yesterday, and I took a train and two buses to get here." Police had to be called before he agreed to leave.
The second incident proved more disturbing. On April 8, after lunch, FM 4 was spotted outside the resident's room. He became hostile and aggressive, pushing past the case manager and two other staff members to enter the room.
The resident's privacy curtain was pulled around her bed while a licensed vocational nurse was providing personal care. FM 4 proceeded to try pulling back the curtain as the nurse held it shut, shouting to the resident: "It's me FM 4, stop saying you do not want to see me. I came here to see you, tell them it is okay for me to see you, tell them it is okay for me to be here."
The resident was physically shaking her head no and was visually upset and tearful as she kept her eyes closed and continued shaking her head. Staff intervened to prevent further interaction and police were called. FM 4 was escorted out by two male staff members while cursing profanities.
The case manager later told inspectors that FM 4's voice was "very aggressive, very loud" and he was yelling "God dammit you know you want to see me, why are you telling them you do not want to see me!" The resident was crying and very shaken up. The case manager described the way FM 4 was talking and acting as "verbally and emotionally abusive."
The licensed vocational nurse who was providing care said FM 4 was shouting multiple things at the resident, including "F the police" while trying to pull the privacy curtain open. The resident was "visibly in fear, shaking, and traumatized," the nurse said. The interaction was "verbal abuse and emotional abuse by the way he was talking to the resident and the response the resident had."
After the April 8 incident, the resident reported feeling anxious and required anti-anxiety medication. A physician ordered Ativan and psychiatric consultation for depression and anxiety. The resident needed the medication again the next day, telling nurses she was "visibly shaken and anxious."
The resident later told inspectors the situation was "mentally exhausting" and she was scared just hearing FM 4's voice when he got into the facility. She had been provided a number to call for therapy but had not yet set up an appointment.
But the facility's abuse coordinator, who was also the administrator, failed to conduct a proper investigation. She was incorrectly informed that FM 4 had not entered the resident's room during the second incident and that staff had been able to stop him. Based on this misinformation, she did not believe abuse had occurred and did not report the incident to state agencies.
Only when inspectors showed her the detailed medical records did the administrator realize the severity of what had happened. She learned for the first time that FM 4 had entered the room, was shouting at the resident, and that the resident was crying and shaking her head no.
"It was important staff members reported accurate descriptions of events because that determined the course of action she takes and if an incident needed to be reported to the state agency," the administrator told inspectors. She acknowledged that according to the facility's abuse policy, mental abuse included harassment, and if there was an allegation of abuse, the incident needed to be thoroughly investigated and reported immediately.
The administrator had never spoken to the resident herself about the incidents. She also revealed that the resident's name remained displayed outside her door throughout her stay, potentially making it easier for FM 4 to locate her room. She noted that hospitals typically do not display names outside rooms of violence victims for patient safety.
After the second incident, the administrator became worried about the resident's safety and had staff reach out to the resident's insurance to request a transfer to another facility, but the insurance company declined.
The facility's policy required protecting residents from further abuse by making room changes as needed, but there was no evidence the resident was offered a room change after either incident. The policy also required thorough investigation including interviews with the resident, witnesses, and a review of circumstances surrounding incidents.
During the same inspection, federal surveyors found serious problems with wound care. A resident admitted with heel blisters saw both wounds deteriorate into infected, unstageable pressure injuries requiring emergency hospitalization.
The 35-year-old resident had been admitted from a hospital with a left heel blister and right heel suspected deep tissue injury. The hospital had recommended pressure injury prevention protocols including repositioning every two hours and heel protection devices.
But the facility's treatment nurse failed to properly document the wounds upon admission, conduct required weekly assessments, or notify physicians when the wounds worsened. When the left heel wound developed a foul odor and areas of dead tissue on April 14, staff still did not complete a change of condition assessment or immediately notify the physician.
Family members noticed the deteriorating condition first. One family member found the resident in pain on April 13, removed her sock and bandage, and was "shocked to see the wound looked worse, and the wound smelled." The family member alerted staff that evening.
By April 16, both heel wounds had been reclassified as unstageable pressure injuries. The left heel wound measured 6.5 centimeters by 7.0 centimeters with 75 percent dead tissue, 20 percent slough, and 5 percent new tissue growth. The resident was transferred to the emergency room on April 17 with heel pain.
At the hospital, the resident received intravenous antibiotics, morphine for pain, and fluids. A wound culture showed bacterial infection. The family was told specialists would evaluate whether surgery was needed, and the resident was anxious about potentially losing her foot.
The facility's director of nursing told inspectors she was not aware of the resident's wounds until the inspection interview. Weekly wound assessments had not been completed as required by facility policy. The registered dietitian was also unaware of the wounds and had not provided nutritional support for wound healing until April 18.
"The treatment nurses were not competent in wound documentation and tracking as evidenced by the lack of documentation in the resident's chart and the failure to complete a change of condition when a decline in the wound was noted," the director of nursing acknowledged.
The inspection found additional problems with care planning, therapy services, and safety protocols. One resident who had fallen four times in four months did not have the required fall risk sticker on his door, leading staff to believe incorrectly that he was not at high fall risk.
Another resident lost the ability to perform standing transfers but was not evaluated by physical therapy for potential interventions to maintain mobility. The resident told inspectors he felt "frustrated that he could not stand anymore" and would "find a way to stand by himself even if it was not safe."
Federal inspectors cited the facility for failing to protect residents from abuse, provide adequate wound care, maintain resident mobility, and follow safety protocols. The violations had minimal to actual harm levels, affecting few to some residents at the 120-bed facility on East Anaheim Street.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shoreline Healthcare Center from 2025-04-18 including all violations, facility responses, and corrective action plans.