LONG BEACH, CA - A federal inspection at Shoreline Healthcare Center revealed staff failed to protect a domestic abuse victim from repeated unwanted visits by her abuser, resulting in significant emotional trauma that required emergency anti-anxiety medication.
Physical Abuse Victim Admitted After Hospital Stay
A resident admitted to Shoreline Healthcare Center in March 2025 came directly from a hospital where she was treated for injuries sustained during physical abuse by a family member. Hospital records documented "traumatic ecchymosis" (bruising) from the assault, and both Adult Protective Services and police had been notified of the abuse before her nursing home admission.
The resident's medical history revealed years of abuse by the family member, including verbal, emotional, financial, and physical mistreatment. Multiple police reports had been filed over the years, but the resident had previously reconciled with her abuser until the final incident that led to her hospitalization and decision to press charges.
Upon admission, the resident clearly expressed that she did not want any contact with her abuser and felt threatened by him. Her care plan specifically documented her fear of being discharged home due to the abuse history.
Security Failures Allow Repeated Intrusions
Despite clear documentation of the resident's wishes and safety concerns, facility staff failed to prevent her abuser from accessing the building on two separate occasions in March and April 2025.
The first incident occurred on March 18, 2025, when the abuser arrived at the facility demanding to visit the resident. When staff informed him of the resident's wishes not to see him, he became agitated and used profanity. Police intervention was required before he agreed to leave the premises.
The second incident was significantly more severe. On April 8, 2025, the abuser bypassed facility security by following another visitor into the building. When staff attempted to stop him from entering the resident's room, he became hostile and aggressive, physically pushing past the case manager and two other staff members.
Privacy Violation During Personal Care
The most disturbing aspect of the April 8 incident occurred when the abuser forced his way into the resident's room while she was receiving personal care. A nursing assistant was providing perineal care, and the resident's privacy curtain was drawn around her bed for dignity and privacy.
The abuser attempted to pull back the privacy curtain while shouting at the resident, despite a Licensed Vocational Nurse holding it closed. The resident's private areas were exposed during this struggle, creating both a privacy violation and additional trauma.
During this intrusion, the abuser yelled aggressively at the resident: "It's me, 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." The resident responded by physically shaking her head "no" while crying and keeping her eyes closed.
Resident's Traumatic Response Requires Medical Intervention
The emotional impact on the resident was immediate and severe. Following the April 8 incident, she experienced significant emotional distress and anxiety. Her physician ordered emergency anti-anxiety medication (Ativan 0.5 mg) and a psychiatric consultation for depression and anxiety management.
Medical documentation showed the resident was "visibly shaken and anxious" and specifically requested anti-anxiety medication. She reported feeling scared just hearing the abuser's voice and described the situation as "mentally exhausting."
The incident created lasting psychological effects. Staff noted that the resident became visibly upset even at the mention of the abuser's name, and her sleep patterns were disrupted due to ongoing anxiety and worries about potential future encounters.
Administrative Failures in Incident Response
The facility's administrator, who served as the abuse coordinator, acknowledged significant failures in handling these incidents. She admitted to being incorrectly informed about the severity of the April 8 incident and stated that if she had known the full details, she would have handled the situation differently.
Crucially, the administrator failed to report the April 8 incident to state agencies as required, despite facility policy mandating immediate reporting of abuse allegations. She also acknowledged never personally interviewing the resident about the incidents, which violated the facility's own investigation procedures.
Safety Protocols Overlooked
Federal regulations require nursing homes to protect residents from abuse and ensure their safety regarding visitors. The facility's own policies specifically stated that residents have the right to deny or withdraw consent for visits at any time.
The case manager suggested implementing safety measures similar to those used in hospitals for violence victims, such as not displaying the resident's name outside her room. However, there was no evidence that facility administration acted on this recommendation.
Additionally, the resident remained in the same room throughout her stay, despite policy allowing for room changes when necessary to protect residents from further abuse. The administrator could not provide evidence that a room change was offered after either incident.
Regulatory Violations and Required Standards
The inspection findings violated federal regulation F610, which mandates that nursing homes ensure each resident's right to be free from abuse. The regulation defines mental abuse as including harassment and threats, both of which occurred during the April 8 incident.
Facility policy required thorough investigations of all abuse allegations, including resident interviews, witness statements, and documentation of results. The administrator's failure to conduct a proper investigation and report the incident represented a serious breach of these requirements.
Medical Significance of Emotional Trauma
For elderly residents with existing mental health conditions, re-traumatization can have severe consequences. The resident already had diagnosed major depressive disorder and anxiety disorder, making her particularly vulnerable to psychological harm from these encounters.
The need for emergency psychiatric medication and consultation demonstrates the significant medical impact of the facility's security failures. Anxiety disorders in nursing home residents can lead to sleep disturbances, appetite changes, and worsening of existing medical conditions if not properly managed.
Industry Standards for Vulnerable Residents
Standard practice in healthcare facilities requires special protections for domestic violence victims. These typically include restricting access to the victim's room information, enhanced security screening of visitors, and immediate intervention when unwanted contact occurs.
The facility's failure to implement basic safety measures, such as removing the resident's name from her door or offering alternative accommodations, fell below accepted industry standards for protecting vulnerable residents.
This case highlights the critical importance of comprehensive safety planning for residents who have experienced domestic violence, particularly in institutional settings where they may feel trapped and unable to escape unwanted contact.
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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