LONG BEACH, CA - Federal inspectors documented serious lapses in resident protection at Shoreline Healthcare Center after facility administrators failed to properly investigate harassment of a physical abuse victim whose alleged abuser repeatedly gained unauthorized access to her room.
Abuse Victim Admitted After Hospital Stay
The resident, referred to as Resident 2 in federal inspection documents, was admitted to the facility on March 16, 2025, following hospitalization for confirmed physical abuse that caused traumatic bruising. Adult Protective Services and police had been notified of the abuse by the hospital, and an active APS case remained open against the family member identified as FM 4.
The resident's medical records clearly documented her traumatic history, noting she had experienced "verbal, emotional, financial, and physical abuse" from FM 4 for years. Multiple police reports had been filed previously, but the resident had repeatedly reconciled with the abuser until the final incident that led to her hospitalization.
Medical documentation indicated the resident had intact cognitive abilities and was making medical decisions with assistance from her sister, while explicitly noting "do not give any information to FM 4" in her treatment plan.
First Unauthorized Entry Incident
On March 18, 2025, FM 4 arrived at the facility demanding to visit the resident despite her expressed wishes to have no contact. When the case manager informed him of the resident's refusal to see him, FM 4 became agitated and walked toward her room stating "that is a lie! I was just there yesterday, and I took a train and two buses to get here."
The case manager asked FM 4 to wait in the lobby while confirming the resident's wishes. The resident again stated she did not want any calls or visits from FM 4. When this message was relayed, FM 4 became hostile, using profanity. Police intervention was required before he agreed to leave the facility.
Following this incident, the resident's chart was updated and all staff were notified of her wishes regarding FM 4's visits.
Second Intrusion Results in Trauma
Despite security measures, FM 4 gained unauthorized access to the facility again on April 8, 2025. This time, he pushed past the case manager and two other staff members to reach the resident's room. A privacy curtain had been drawn around the resident's bed while she was receiving personal care from nursing staff.
FM 4 attempted to pull back the privacy curtain while a Licensed Vocational Nurse held it shut, shouting "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."
Medical records documented that the resident was "physically shaking her head No" and was "visually upset and tearful" as she kept her eyes closed and continued rejecting the contact. The resident was receiving intimate personal care at the time, and her privacy was compromised during the incident.
Staff testified that FM 4's behavior was "verbally and emotionally abusive" based on his aggressive tone and the resident's traumatic response. Two male staff members were required to escort him from the building as he continued using profanity.
Medical Impact on Resident
The unauthorized intrusions had significant medical consequences for the resident. Following the April 8 incident, the attending physician ordered anti-anxiety medication after the resident reported feeling anxious and showed signs of emotional distress.
The resident was prescribed Ativan 0.5 milligrams every eight hours as needed for anxiety manifested by verbalization of anxiousness with mild tremors. She received the medication on April 9 after reporting visible shaking and requesting anti-anxiety treatment.
A psychiatric consultation was also ordered to address depression and anxiety stemming from the traumatic encounters. The resident's care plan was updated to include interventions for "potential for psychosocial well-being problems related to family discord."
During interviews with federal inspectors, the resident declined to elaborate on the prior abuse but described feeling scared upon hearing FM 4's voice and finding the situation "mentally exhausting."
Facility's Inadequate Response
The facility's abuse coordinator, who served as administrator, acknowledged being aware of both incidents but admitted to conducting no thorough investigation of the April 8 encounter. She stated she was initially misinformed that FM 4 had not actually entered the resident's room during the second incident.
The administrator told inspectors she believed the situation involved "family dynamics" rather than abuse and therefore did not report the incident to state agencies as required by federal regulations.
Only after reviewing the detailed medical documentation during the federal inspection did the administrator recognize the severity of the situation. She acknowledged that FM 4's behavior met the facility's own definition of mental abuse, which includes harassment.
Federal nursing home regulations require facilities to protect residents from abuse and investigate all allegations thoroughly. The facility's own policy mandates reporting abuse allegations to appropriate state agencies within specified timeframes.
Safety Measures Never Implemented
Despite the repeated security breaches, the facility failed to implement basic protective measures. The resident's name remained displayed outside her room throughout her stay, potentially allowing FM 4 to locate her more easily.
The case manager had suggested removing the resident's name from her door, similar to practices used in hospitals for violence victims, but this recommendation was not implemented. No room change was offered to enhance the resident's safety after either incident.
The administrator only attempted to arrange a transfer to another facility after the second incident, but the resident's insurance declined the request.
Regulatory Violations Confirmed
Federal inspectors cited the facility for two violations related to resident protection and abuse investigation. The citations noted that the facility failed to ensure residents' right to be free from abuse and failed to respond appropriately to alleged violations.
The violations were classified as causing "minimal harm or potential for actual harm" affecting few residents. However, inspectors emphasized that the deficient practices created potential for additional mental abuse from the resident's alleged abuser, potentially causing increased anxiety and emotional distress.
Nursing home regulations specifically require facilities to protect residents from abuse by visitors and ensure proper investigation of all allegations. Facilities must also provide reasonable clinical and safety restrictions while respecting residents' rights to refuse visits from specific individuals.
Medical Standards for Abuse Response
Standard protocols for healthcare facilities serving abuse victims emphasize the importance of trauma-informed care. This approach recognizes the widespread impact of trauma and seeks to avoid re-traumatization during the healing process.
Proper response to abuse disclosures includes immediate safety planning, thorough documentation, appropriate reporting to authorities, and ongoing emotional support. Healthcare providers should validate the victim's experience and respect their autonomy in making decisions about contact with alleged abusers.
Mental health professionals emphasize that re-exposure to abusive individuals can significantly impede recovery and potentially worsen existing trauma symptoms. The provision of anti-anxiety medication following the incidents demonstrates the measurable impact of the facility's security failures on the resident's wellbeing.
Shoreline Healthcare Center was required to submit a plan of correction addressing the identified deficiencies in resident protection and abuse investigation procedures.
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.
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