Horizon Post Acute: Resident Abuse Violation - AZ
The October attack at Horizon Post Acute and Rehabilitation Center left the victim with facial lacerations requiring medical strips, bruises across his shoulder and arm, and scratches on his face and ears. Police arrested the attacker and took him to jail.
Federal inspectors found that facility managers had deliberately paired the two men as roommates after the attacker's previous assault on another resident in May, choosing the victim because he was "polite, quiet and had no issues."
The assault began when the attacker started "yelling, cussing and calling names" at his roommate, according to the victim's account to inspectors. The attacker threatened that "he was going to f@&k me up and kill," then crashed into an over-the-bed table placed next to the curtain separating their beds.
"Resident #2 started gouging his eyes," the victim told inspectors during their October 31 interview. "Then Resident #2 started punching Resident #1."
The victim said he refused to fight back because "Resident #2 was old." But when he called his attacker "a girl," the assault escalated.
The attacker grabbed a black metal water cup from the bedside nightstand and began beating the victim with it. The victim pointed inspectors to white medical strips covering lacerations on the left side of his face near his eye and eyebrow, explaining that his roommate had "scratched my face and ears."
Inspectors observed a dark bruise on the victim's left shoulder, scratches on his upper arm and shoulder, bruising in the crook of his elbow, and additional scratches on his lower arm. The victim confirmed he was experiencing pain from the injuries.
Director of nursing Staff #5 documented the victim's injuries as "a laceration, scratches, abrasions and redness at the neck." The attacker also sustained injuries during the fight, including "a small abrasion to the second digit knuckle and the first digit knuckle was swollen to the right hand."
The facility's decision to room the two men together came directly after the attacker's previous assault on a different resident in May. Assistant director of nursing Staff #4 told inspectors that the attacker "did have a history of inappropriate behavior before" but could not remember the specific date.
Following the May incident, managers had separated the attacker from his previous victim, placing them at "separate stations" and notifying "all the same parties." The attacker received psychiatric and social services treatment and was initially housed alone.
But the facility "needed the room," according to Staff #5. Managers selected the eventual victim as the new roommate specifically because "he is polite, quiet and had no issues."
Staff #5 explained the roommate selection process to inspectors: "They keep the room dark, wear headphones and have not had any issues between them." She added that Staff #4 checked on the attacker "as part of her angel rounds."
The director of nursing acknowledged to inspectors that "there were no prior incidents between the two residents. That is one reason why the residents were paired up."
But the pairing decision ignored what Staff #5 described as a fundamental risk: "The risk for residents abusing other residents is harm."
When the October assault occurred, assistant director of nursing Staff #4 was working in the building but did not witness the attack. She told inspectors that by the time she responded, "Resident #2 had already left the room."
Staff #4's immediate actions included ensuring "the residents were safe," assessing the patients, and notifying both the director of nursing and the administrator. She also called police, who "came right away" according to her account.
The attacker never returned to the shared room after the assault.
One certified nursing assistant, Staff #3, told inspectors she "did not see the incident" but understood the reporting protocol: "when you see abuse that you report it to the abuse coordinator."
Inspectors attempted to interview another nursing assistant, Staff #8, but received no response despite leaving a voicemail message requesting a return call.
The facility's October 2024 policy on abuse prevention states that "Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion."
A separate resident rights policy reviewed in May 2025 reinforces that residents have "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."
Federal inspectors cited the facility for failing to protect residents from abuse, finding that actual harm occurred to a few residents. The violation carries the inspection tag F 0600.
Horizon Post Acute and Rehabilitation Center is disputing the citation.
The victim remains at the facility, now without the roommate who threatened to kill him, gouged his eyes, and beat him with a metal cup while managers who knew about previous violence did nothing to prevent it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Horizon Post Acute and Rehabilitation Center from 2025-10-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 12, 2026 · Our methodology
Horizon Post Acute and Rehabilitation Center in GLENDALE, AZ was cited for abuse-related violations during a health inspection on October 31, 2025.
Police arrested the attacker and took him to jail.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Horizon Post Acute and Rehabilitation Center?
- Police arrested the attacker and took him to jail.
- How serious are these violations?
- These are very serious violations that may indicate significant patient safety concerns. Federal regulations require nursing homes to maintain the highest standards of care. Families should review the full inspection report and consider whether this facility meets their safety expectations.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GLENDALE, AZ, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Horizon Post Acute and Rehabilitation Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 035159.
- Has this facility had violations before?
- To check Horizon Post Acute and Rehabilitation Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.