Horizon Post Acute And Rehabilitation Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.
FORM CMS-2567 (02/99) Previous Versions Obsolete
attempted on October 31, 2025 at 10:47 a.m. with certified nursing assistant (CNA)/ Staff #8. Staff #8 did not answer her phone, however a voice mail message was left to return the call. No call was returned by Staff #8.An interview was conducted on October 31, 2025 at 11:12 a.m. with (CNA) Staff #3 and revealed that she did not see the incident between Resident #1 and Resident #2, but stated when you see abuse that you report it to the abuse coordinator. Trainings are done when staff first start.An interview and
observation was conducted on October 31, 2025 at 11:16 a.m. with Resident #1 revealed that Resident #2 started yelling, cussing and calling names and said something that he was going to f@&k me up and kill.
He then came over and crashed into the over the bed table that was placed next to the curtain. Resident #1 did not want to hit him and Resident #2 started gouging his eyes. Resident #1 said some cuss words and told Resident #2 he could not hit. Then Resident #2 started punching Resident #1. Resident #1 then called Resident #2 a girl. Resident #2 then started punching Resident #1 with a black metal looking water cup (Resident #1 pointed to a bedside night stand where the black metal cup was at). Resident #1 pointed to his left side of face by his eye and eyebrow where white looking strips were placed, and stated Resident #2 scratched my face and ears. Resident #1 then pointed to his left shoulder and a dark colored bruise was noted on the ball of the shoulder, scratches on upper arm/shoulder, bruise to the antecubital area and more scratches to his lower arm. Resident #1 stated that he does have pain. The police came, pressed charges and took Resident #2 to jail. Resident #1 did not hit Resident #2 because Resident #2 was old.An interview was conducted on October 31, 2025 at 11:34 a.m. with assistant director of nursing (ADON) Staff #4 and revealed that she was working in the building when the incident happened, did not witness the event.
Resident #2 had already left the room. Made sure the residents were safe, assessed the patients, notified DON Staff #5 and Administrator Staff #7, notified the police and started talking to everyone. Resident #2 did not go back into the room. Resident #2 did have a history of inappropriate behavior before, but Staff #4 does not remember the date. The police came right away.An interview was conducted on October 31, 2025 at 11:44 a.m. with director of nursing services (DON)/ Staff #5 and revealed that she was aware of the incident between Resident #1 and Resident #2. Injuries were noted and Resident #1 had a laceration, scratches, abrasions and redness at the neck. Resident #2 had injuries to his hands, resulting in a small abrasion to the second digit knuckle and the first digit knuckle was swollen to the right hand. There were no prior incidents between the two residents. That is one reason why the residents were paired up. They keep
the room dark, wear headphones and have not had any issues between them. Staff #4 checks on him as part of her angel rounds. Resident #2 had a prior incident with another resident in May. At that time both residents were separated, separate stations and all the same parties notified. Resident #2 was being seen by psych and social services. Resident #2 was in his own room for a while, but we needed the room.
Resident #1 was selected because he is polite, quiet and had no issues. The risk for residents abusing other residents is harm.Review of the facility's policy titled, Abuse: Prevention of and Prohibition Against, last revision date of October 2024 revealed Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.Review of the facility's policy titled, Resident Rights with a reviewed date May 2025 revealed: The Resident has the right to be free from verbal, sexual, mental, or physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience or for other than treating medical symptoms.
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Horizon Post Acute and Rehabilitation Center in GLENDALE, AZ 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 GLENDALE, AZ, (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 Horizon Post Acute and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.