Community Care Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
2, the statement indicated Resident 1 was in HS 1's face regarding dirty toilet paper. The statement indicated Resident 1 was upset because HK 1 gave Resident 1's toilet paper without putting on any gloves.
The statement indicated Resident 1 and HS 1 were cussing at each other.? During a review of the facility's provided investigation statement dated 9/9/2025, and written by HS 1, the statement indicated Resident 1 yelled out your housekeeping is a ‘bitch.' The statement indicated HS 1 yelled out of anger shut the fuck up, and walked into the janitor closet. During a review of HS 1's employee file, the file indicated the following:? -? ?Patient's Rights Policy dated 11/6/2018 and signed by HS 1, indicated staff may not verbally or physically abuse any patient for any reason. The policy indicated staff may not verbally or physically strike a patient intentionally because they are angry or for any other reason. The policy indicated staff must have a great deal of patience and not be influenced to react to a patient's behavior by verbally or physically striking
the patient.? - ? ?Walk Away Policy dated 11/6/2018 and signed by HS 1, indicated that any staff member who becomes frustrated when assisting a resident must walk away from the situation. The policy indicated if at any time a staff member becomes frustrated with a resident, he or she must walk away from the situation immediately and seek assistance. During an interview on 9/12/2025 at 10:19 AM, the Administrator (ADM) stated Resident 1 was already verbally aggressive towards HK 1, and that HS 1 should not have responded to Resident 1 by returning the verbal abuse since it could escalate verbal abuse to physical abuse. The ADM stated HS 1 would be terminated During an interview on 9/12/2025 at 10:39 AM with PC 1, PC 1 stated he heard a commotion from nursing station 1 and observed Resident 1 being verbally aggressive towards HS 1. PC 1 stated both Resident 1 and HS 1 were yelling at each other. PC 1 stated he separated Resident 1 and HS 1 to prevent situation from escalating. During a telephone interview on 9/12/2025 at 10:52 AM with HS 1, HS 1 stated as he was coming out of the janitor's closet, he heard Resident 1 yelling and was upset about the toilet paper. HS 1 stated Resident 1 was yelling at HK 1, and when HS 1 tried to talk to Resident 1 to deescalate the situation, Resident 1 came closer, and said fuck you, you faggot, she's (HK 1) a bitch. HS 1 stated he tried to calm Resident 1 down and explained the protocols when housekeeping provides toilet paper to the residents. HS 1 stated Resident 1 continued yelling and HS 1 said to Resident 1 man, shut the fuck up already, and walked back to the janitor closet.? During an
interview on 9/12/2025 at 11:20 AM, infection prevention nurse (IPN) stated Resident 1 could get aggressive and had the tendency to antagonize others. IPN stated Resident 1 was verbally aggressive, and when witnessed, staff must try to deescalate the situation, but also walk away and call for someone to assist the resident to calm down. IPN to prevent further incidents, de-escalation of the situation must be done. During an interview on 9/12/2025 at 11:28 AM with Resident 1, Resident 1 stated he complained to HS 1 about toiled paper and HS 1 got mad and started shouting. Resident 1 stated because HS 1 started shouting it got me mad, so I started shouting back at him. Resident 1 stated he could not recall what was said, but stated staff separated Resident 1 and HS 1. Resident 1 stated the incident made him feel mad because he did not understand why HS 1 raised his voice.? A review of facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, physical abuse, and physical or chemical restraint not required to treat resident's symptoms.?
Event ID:
Facility ID:
05A109
If continuation sheet
COMMUNITY CARE CENTER in DUARTE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DUARTE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMMUNITY CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.