The March 31 assault at Park Avenue Healthcare & Wellness Center began when Resident 7 was sitting in the hallway swinging a doll and saying offensive language in Spanish repeatedly. When the doll touched Resident 9, that resident reacted by punching Resident 7 in the face with a closed fist multiple times.
Resident 7 suffered swelling and discoloration on the left cheek and both eyelids, along with bleeding inside the mouth. The resident complained of sudden pain rated six out of 10. Emergency department physicians documented bilateral facial contusions and a closed head injury after the facility transferred the resident for CT scan and further evaluation.
Two weeks later, when federal inspectors interviewed Resident 7, light gray discoloration remained around both eyes. "A guy with two hands, hit me on the face, Boom, Boom, in my eyes," the resident said, raising both fists and punching the air. "I was bleeding in the mouth. It hurt."
But the violence didn't stop there.
Within a minute of the first assault, Resident 9 wheeled close to another resident standing near the nurse's station. Resident 9 pulled Resident 8's shirt and necklace from behind, breaking the necklace, then held Resident 8 around the neck in what staff described as a chokehold position. Resident 8 developed redness on the left side of the neck.
Licensed Vocational Nurse 6 witnessed both attacks. The nurse told inspectors that Resident 7's mouth was bleeding and the resident had swelling around the eyebrows, cheeks and lips after being struck.
The facility's Director of Nursing was unequivocal about what happened. "It was not ok for Resident 9 to pull Resident 8's necklace or hold Resident 8 around the neck," the director told inspectors. "Resident 9 used a closed fist and harmed Resident 7 more than once. Resident 9's actions were willful, and this was abuse."
All three residents involved had severe cognitive impairments from dementia. Resident 9 also had bipolar disorder and used a walker with no impairment to arms or legs. When emergency department staff evaluated Resident 9 after the attacks, the resident told them: "She was asking for it and I was trying to kill her."
The facility transferred both Resident 7 and Resident 9 to the hospital on March 31. Resident 7 went for treatment of facial injuries. Resident 9 was evaluated for aggressive behavior and psychosis, with physicians noting the resident was at risk for danger to others.
Staff supervision failures enabled the second attack. Certified Nursing Assistant 5 told inspectors that after the first assault, nurses stayed with Resident 7 while the assistant watched Resident 9 from near a utility room in the hallway. But when Resident 8 approached, Resident 9 was able to grab and hold that resident around the neck.
The assistant acknowledged that during resident altercations, "the residents needed to be separated to avoid further physical contact and staff needed to stay with the residents involved in the altercation."
Multiple staff members confirmed this protocol. Certified Nursing Assistant 7 said facility training required staff to stay with residents involved in altercations "to avoid another altercation." Licensed Vocational Nurse 7 explained it was important to supervise such residents "because the aggressive behavior could escalate and could result in another altercation."
The facility's own policy required one-on-one supervision when a resident's behavior became abusive or compromised safety. The policy stated that residents displaying combative behaviors should receive "prompt and appropriate interventions" and that if behavior became "abusive, hostile, or unmanageable," the charge nurse should "maintain one on one supervision of the resident until the behavior subsided."
Yet no such supervision occurred between the two attacks.
The inspection also revealed a separate supervision failure that resulted in a resident fall. Resident 1, who had a history of falling and required prompt response to assistance requests, waited an hour after pressing the call light without any staff response. The resident was trying to get help for a confused, crying roommate.
When no one answered the call light despite yelling down the hall, Resident 1 attempted to transfer into a wheelchair to go to the nurse's station for help. The resident fell to the ground during the transfer.
Resident Council minutes from April 9 documented ongoing problems with call light response times, noting that residents were complaining "the call takes a long time to be answered (11 pm to 7 am shift) mainly."
The facility also failed to develop a care plan for Resident 7 after the assault and head injury. Despite emergency department documentation of a closed head injury from being struck in the head multiple times, the facility never created an individualized care plan to address the possible head injury.
The Medical Records Supervisor confirmed that Resident 7's chart contained no care plan regarding being struck in the face multiple times. The Director of Nursing acknowledged that Resident 7 lacked a care plan addressing the possible head injury, stating that care plans were "important to provide proper care and effective interventions for the individualized and overall care" of residents.
The facility's own policy required care plan updates based on assessed needs, including "onset of new problems" and "change of condition." A closed head injury from assault would clearly qualify as both.
Park Avenue Healthcare & Wellness Center, located at 1550 North Park Avenue in Pomona, has operated since at least 2012 based on policy dates in the inspection record. The facility admits residents with complex conditions including dementia, schizophrenia, psychosis, and bipolar disorder.
The inspection found that three of the four residents reviewed received inadequate supervision, with actual harm occurring in multiple cases. The facility's policy promised a "safe environment for residents and facility staff" but failed to prevent willful abuse that left one resident hospitalized with a head injury and facial trauma that was still visible weeks later.
When inspectors spoke with Resident 7 more than two weeks after the assault, the discoloration around both eyes served as a lasting reminder of the facility's failure to protect vulnerable residents from preventable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Avenue Healthcare & Wellness Center from 2025-04-16 including all violations, facility responses, and corrective action plans.
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