Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Horizon Post Acute And Rehabilitation Center during CMS and state inspections, most recent first.
Misappropriation of Resident Jewelry: A resident admitted for hospice respite had an inventory listing two rings and a chain with a cross, but the family later reported the jewelry missing after the resident died. Interviews showed conflicting accounts about whether the daughter took the jewelry, whether mortuary staff removed it, and whether staff retained it in a zip-lock bag at the nurse station. The administrator said video showed staff exchanging the bag, but the investigation remained inconclusive.
A cognitively intact resident with multiple comorbidities, including CKD and acute kidney injury with metabolic acidosis, repeatedly expressed not feeling well and requested to go to the ER. Despite active orders for labs, sodium bicarbonate, and a Foley catheter to evaluate possible obstructive uropathy, there was no nursing progress note, no documented assessment, and no vital signs recorded on the day the resident requested transfer. The resident told a friend that staff would not send him to the hospital because he did not meet criteria; an LPN told the friend and later the fire department that the resident did not meet criteria and there was no physician order for transfer, leading to cancellation of the 911 response. Staff interviews showed inconsistent understanding of residents’ rights to request hospital transfer and uncertainty about calling or assisting with 911, and the facility lacked a policy on emergent hospital transfer, despite policies requiring honoring resident rights and documenting changes in condition. The resident was later found unresponsive and pronounced deceased.
Two cognitively intact residents with complex medical and psychiatric histories were involved in a physical altercation in their shared room, resulting in one resident sustaining lacerations, scratches, and bruising after being assaulted with a metal cup. The aggressor had a prior history of inappropriate behavior with other residents, and although interventions had been implemented previously, the facility did not prevent this subsequent incident of abuse.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, resulting in inadequate staff guidance and inconsistent training on recognizing and reporting such incidents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with moderate cognitive impairment and physical disabilities was physically assaulted by his cognitively intact roommate following ongoing verbal aggression and documented behavioral concerns. Despite repeated psychiatric notes indicating roommate issues and a care plan highlighting the risk of abusive behavior, the two continued to share a room, leading to a physical altercation and injury. The DON confirmed that such situations should have been addressed to prevent abuse, in accordance with facility policy.
The facility was found to have a medication error rate of 15.79% due to multiple instances where LPNs administered the wrong medication, gave medications late, or failed to follow prescribed administration times for several residents with complex medical conditions. LPNs reported being unable to complete medication passes on time due to workload, and the DON acknowledged the occurrence of late and incorrect medication administrations.
Staff did not follow infection control protocols for two residents with indwelling devices and wounds. A resident's Foley catheter bag was left on the floor without a privacy bag, and an LPN did not perform hand hygiene before or between glove changes during PICC and feeding tube care. For another resident with pressure injuries and EBP orders, wound care was performed without staff donning gowns as required. These actions were contrary to facility policy and physician orders.
A resident with multiple medical conditions and a documented DNR preference had conflicting code status information in the facility's records, with the electronic health record listing Full Code while both the advanced directive and code book indicated DNR. Staff interviews confirmed the inconsistency, and the baseline care plan lacked documentation of the resident's treatment preferences, resulting in the resident's wishes not being accurately reflected across all records.
Two residents with documented mental health diagnoses did not have accurate PASRR screenings or appropriate referrals to the state mental health authority. Staff failed to update screenings and make referrals after new diagnoses were identified, and interviews revealed a lack of communication and awareness regarding changes in residents' mental health status.
A resident with multiple medical conditions was found with an over-the-counter Omeprazole 20 mg medication left at the bedside without assessment or authorization for self-administration. Staff interviews and policy review confirmed that medications are not permitted at the bedside unless the resident is properly assessed and authorized, and no such assessment or order was present.
Misappropriation of Resident Jewelry
Penalty
Summary
The facility failed to ensure that one of three sampled residents was protected from the wrongful use of the resident’s belongings when a resident’s jewelry could not be accounted for after admission and death during a hospice respite stay. The resident was admitted with diagnoses including unspecified severe protein calorie malnutrition and was in the facility for one day only. The admission inventory documented two rings and a chain with a cross, and the resident’s daughter later reported that the resident had been wearing two rings and a crucifix necklace at admission, but the jewelry was not present when she saw the resident at the mortuary. Records and interviews showed conflicting accounts about the jewelry’s handling. Social services staff stated the daughter was present during the inventory and said she would take the jewelry with her. The social services staff member also stated she did not see the daughter leave with the jewelry and that staff searched the room, notified the administrator, and reviewed video. An LNA stated she saw a necklace with a cross during care, and after the resident died, mortuary personnel removed the jewelry and placed it on the bedside table; she then placed a necklace and a ring in a zip-lock bag and gave it to the RN. The RN stated she received a zip-lock bag containing jewelry and later handed it to the day LPN, who said she placed it under the computer tray and forgot to turn it in to social services before leaving. The administrator stated the resident’s inventory included two rings and a chain with a cross, that the family later reported the jewelry missing, and that the facility investigated by interviewing staff, reviewing video, and contacting hospice and the mortuary. The administrator also stated the video showed the nurses exchanging the zip-lock bag near the nurse station and that the jewelry was in the facility’s possession, but it was not known whether it was trashed or shredded. The investigation outcome was documented as inconclusive, and the facility policy stated that resident personal effects are to be inventoried and reasonable steps taken to protect resident property.
Failure to Honor Resident’s Request for Emergent Hospital Transfer and Lack of Assessment/Documentation
Penalty
Summary
The deficiency centers on the facility’s failure to honor a cognitively intact resident’s right to self-determination regarding an emergent transfer to the hospital, and to appropriately assess and document his condition when he requested to go to the emergency room. The resident had multiple significant diagnoses, including type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease, peripheral vascular disease, pulmonary hypertension, anemia, and a left below-knee amputation. A recent MDS showed a BIMS score of 13, indicating intact cognition, and there was no documentation of a medical power of attorney or court-appointed decision-maker, meaning the resident was his own decision-maker. In the days leading up to the incident, provider notes documented worsening renal function, acute kidney injury on chronic kidney disease stage III, metabolic acidosis, suspected dehydration, and the need for urgent nephrology follow-up. Orders were written for a nephrology appointment “as soon as possible,” a BMP, and sodium bicarbonate for metabolic acidosis, as well as a Foley catheter to evaluate for outlet obstruction versus neurogenic bladder. On the date the resident requested to go to the hospital, the clinical record contained no nursing progress notes, no documented nursing assessment, and no documentation of the resident’s request or concerns. There was also no evidence that vital signs (blood pressure, oxygen saturation, pulse, respirations, or temperature) were assessed or recorded that day, despite the resident’s ongoing acute medical issues and new orders. The MAR/TAR for that date was blank for the Foley catheter order, and there was no documented change-of-condition monitoring for that date or the following day, even though additional orders were in place for labs and treatment related to acute kidney injury and metabolic acidosis. Staff interviews indicated that CNAs and LPNs had observed that the resident was not doing well in the days before his death, including increased pain with turning, pallor, frequent lab draws, and plummeting renal function. On the day in question, the resident called a friend stating he was not feeling well, felt the facility was not doing enough, and that he had told the nurse he wanted to go to the emergency room but was told he did not meet criteria and would not be sent. The friend reported calling the resident’s floor nurse, who reiterated that the resident did not meet criteria for a 911 transfer and that the doctor would not authorize a hospital transfer. The friend then called 911 and was connected to the fire department, which later cancelled its response after speaking with the nurse, who stated there was no physician order and the resident did not meet criteria to be sent out. The nurse later told the provider that the resident’s desire to go to the hospital was due to dissatisfaction with the food, and no other concerns were relayed. Multiple staff, including the RN, ADON, and DON, stated there was no formal list of criteria for emergent transfer and acknowledged that residents have the right to choose to go to the hospital, yet one LPN stated she was not allowed to call 911 or decide on transfers, and another LPN believed she could not assist a resident in calling 911. The facility had no policy on emergent hospital transfer, and existing policies on resident rights, change of condition reporting, and vital signs required honoring resident rights, assessing and documenting changes in condition, and taking vital signs as warranted by the resident’s condition, which were not followed in this case. Subsequently, a nursing note documented that a nurse entered the resident’s room to administer medications and found him unresponsive and not breathing, with no vital signs, and confirmed DNR status before pronouncing him deceased. Interviews with CNAs and LNAs described the resident as not behavioral, not prone to overreacting, and generally not someone who asked for much, which they felt made his request to go to the hospital significant. The ADON and DON both stated they were not aware of the incident involving the resident’s request to go to the hospital or the fire department contact. The facility’s own policies on resident rights and change of condition, along with federal regulation 42 CFR § 483.10, were cited in relation to the failure to ensure the resident’s right to self-determination and to appropriately assess, document, and respond to his request for emergent hospital transfer.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in an altercation that caused physical injuries. One resident, who was cognitively intact and had a history of hemiplegia, seizures, and psychiatric diagnoses, was involved in a physical altercation with another cognitively intact resident who had a history of multiple sclerosis, depression, and prior verbally abusive behavior. The incident occurred in their shared room, where one resident began yelling, making threats, and then physically assaulted the other using a metal cup, resulting in lacerations, scratches, bruising, and pain. The aggressor had a prior history of inappropriate behavior with other residents, including a previous altercation in May, after which interventions such as separation and psychiatric services were implemented. Staff interviews and documentation revealed that the altercation was not witnessed by staff, but immediate actions were taken after the incident was discovered, including separating the residents and assessing for injuries. The resident who was assaulted described being threatened, punched, scratched, and hit with a metal object, leading to visible injuries that required treatment. The aggressor was arrested by police following the incident. Prior to this event, the two residents had been paired as roommates due to a lack of previous issues between them, despite the aggressor's earlier behavioral concerns with other residents. Review of facility policies confirmed that residents have the right to be free from all forms of abuse, including physical and verbal abuse. However, the facility did not prevent the recurrence of resident-to-resident abuse, as evidenced by the prior incident involving the aggressor and the subsequent physical assault. The lack of effective preventive measures and monitoring contributed to the failure to protect residents from abuse by other residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies to Prevent Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through review of facility documentation and interviews, which revealed that the required policies and procedures were either not in place or not adequately enforced. As a result, there was insufficient guidance for staff on how to recognize, report, and prevent incidents of abuse, neglect, or theft involving residents. Surveyors found that the lack of comprehensive policies and procedures contributed to an environment where staff were not consistently trained or held accountable for preventing and reporting such incidents. No specific resident cases or medical histories were detailed in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with multiple diagnoses, including HIV, hemiplegia, bipolar disorder, and moderate cognitive impairment, was involved in a physical altercation with his roommate, who had multiple sclerosis, major depressive disorder, and was cognitively intact. The altercation occurred after ongoing documented behavioral concerns and verbal aggression from the roommate, which were noted in psychiatric progress notes over several months. Despite these documented issues and the roommate's care plan indicating a potential for verbally abusive behaviors, the two residents continued to share a room. On the night of the incident, the cognitively intact resident struck his roommate in the eye following a verbal exchange, resulting in an abrasion and swelling. Interviews confirmed the history of verbal aggression and the physical altercation. The director of nursing acknowledged that roommates with documented behavioral concerns should be separated and that ongoing issues should have been communicated and addressed. Facility policy required identification and intervention in situations likely to result in abuse, but these measures were not implemented prior to the incident.
Medication Error Rate Exceeds 5% Due to Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by six medication administration errors identified out of 38 opportunities, resulting in a 15.79% error rate. For one resident with diagnoses including viral hepatitis, anxiety disorder, depression, and schizophrenia, an LPN administered Senna instead of the ordered Senna Plus during the morning medication pass. The LPN acknowledged the error after administration. Another resident with coronary artery disease, hypertension, diabetes, thyroid disorder, and depression received multiple morning medications more than one hour past the scheduled time, which the LPN confirmed was outside the facility's policy for timely administration. The LPN reported routinely finishing the morning medication pass late due to the number of residents assigned. A third resident, with orthopedic aftercare, absence of left toes, and type 2 diabetes with hyperglycemia, received sliding scale insulin after breakfast, contrary to the order for administration before meals. The LPN administering the insulin confirmed the timing was incorrect. Multiple LPNs reported to the DON that they were unable to complete medication passes within the required time frame, resulting in late administration. The DON acknowledged the late medication administrations and the associated errors during interviews, and facility policy confirmed that medications should be administered as prescribed and that deviations should be documented.
Failure to Follow Infection Control Protocols for Indwelling Devices and Wound Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols for two residents with complex medical needs. For one resident with a Foley catheter, PICC line, and feeding tube, the Foley catheter drainage bag was observed sitting directly on the floor without a privacy bag, and the emptying spout was in contact with the floor. Additionally, during care procedures involving the PICC line and feeding tube, an LPN did not perform hand hygiene before donning gloves, between glove changes, or after removing gloves, despite handling invasive devices and administering medications. For another resident with multiple pressure injuries and orders for Enhanced Barrier Precautions (EBP), wound care was performed by two staff members who donned gloves but failed to wear gowns as required by EBP protocols. The signage for EBP was present in the room, and the care plan and physician orders specified the use of EBP, but staff did not comply with the gown requirement during wound care. Interviews with staff and the Director of Nursing confirmed awareness of the required infection control practices, including hand hygiene and the use of gowns and gloves for residents on EBP. However, the observed failures to implement these practices during direct care led to deficiencies in the facility's infection prevention and control program.
Failure to Ensure Consistent Code Status Documentation for Resident with DNR Directive
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's code status was accurate and consistent across the medical record. The resident, who was admitted for surgical aftercare and had multiple diagnoses including chronic kidney disease and atrial fibrillation, had a documented preference for Do Not Resuscitate (DNR) status as indicated on both the Advanced Care Directive form and the prehospital directive. Despite this, the electronic health record dashboard and physician order review listed the resident as Full Code, creating a direct conflict with the signed DNR documentation. Interviews with the resident confirmed her choice of DNR status. Staff interviews revealed that code status is typically verified using a code arrest book at the nursing station and the electronic health record dashboard. The registered nurse and social service supervisor both identified the discrepancy between the code book, which correctly reflected the DNR status, and the electronic health record, which incorrectly indicated Full Code. The Director of Nursing also confirmed the inconsistency after reviewing the relevant records and acknowledged that the code book and clinical record should match the physician's orders and the resident's wishes. Facility policy states that advance directives will be recognized and respected, but the process for updating and verifying code status failed in this instance. The baseline care plan did not note the resident's specific treatment preferences, and the weekly review process did not catch the discrepancy between the electronic health record and the code book. This failure resulted in the resident's documented wishes not being accurately reflected in all parts of the medical record.
Failure to Complete Accurate PASRR Screenings and Referrals for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required Pre-admission Screening and Resident Review (PASRR) screenings were completed accurately and that referrals were made to the appropriate state-designated mental health or intellectual disability authority for two residents. For one resident, the initial PASRR Level I screening prior to admission was left mostly blank, and subsequent screenings failed to reflect new diagnoses of schizoaffective disorder, despite documentation in the clinical record and provider notes. The social services staff were not aware of the new diagnosis and did not complete the necessary 30-day review or submit a referral for a Level II PASRR, as required when a new mental health diagnosis is identified. Another resident had a history of multiple mental health diagnoses, including major depressive disorder, mood disorder, bipolar disorder, and anxiety disorder. Despite these diagnoses, the PASRR Level I screening completed years after admission indicated no serious mental illnesses and did not reflect the resident's active diagnoses. No evidence was found that a new PASRR was completed or that a referral was made for a Level II evaluation, even as the resident continued to receive psychotropic medications for these conditions. Interviews with facility staff, including social services and the MDS coordinator, confirmed that the PASRR screenings were not completed in accordance with policy and did not accurately reflect the residents' mental health status. Staff acknowledged that new diagnoses and changes in condition should have triggered new screenings and referrals, but these actions were not taken due to lack of communication and awareness of the residents' updated diagnoses.
Unauthorized Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a resident was found with an over-the-counter medication, Omeprazole 20 mg, left at the bedside without proper authorization or assessment for self-administration. The resident, who was cognitively intact and had multiple diagnoses including a displaced fracture, anemia, chronic pain syndrome, alcohol abuse, and anxiety disorder, was observed with the medication bottle on her bedside table. There was no evidence in the care plan, physician's orders, or assessments that the resident was permitted or assessed to self-administer medications. Additionally, there was no interdisciplinary meeting or documentation supporting self-administration for this resident. Staff interviews confirmed that medications, including over-the-counter drugs, are not allowed to be left at the bedside unless the resident has been properly assessed and authorized to self-administer. The CNA, LPN, physician, and DON all stated that the medication should not have been at the bedside and that the resident was not permitted to self-administer. Facility policies reviewed also required assessment and physician orders for self-administration and specified that medications should not be left in resident rooms if they could cause harm.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Place At Glencroft | 2.3 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of North Glendale | 3.3 mi | ★★★★★ | 1 | 0 |
| Bella Vita Health And Rehabilitation Center | 3.7 mi | ★★★★★ | 3 | 0 |
| Beatitudes Campus | 3.8 mi | ★★★★★ | 5 | 0 |
| Coronado Healthcare Center | 3.9 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.