Horizon Post Acute And Rehabilitation Center
Horizon Post Acute and Rehabilitation Center in GLENDALE, AZ — inspection on October 31, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.