Horizon Post Acute and Rehabilitation Center
4704 West Diana Avenue, Glendale, AZ 85302 · Maricopa County · 196 certified beds · avg 149 residents/day · certified since Apr 6, 1988
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Oct 31, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 26, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (19)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 13, 2026 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Oct 31, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 4, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 16, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 16, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 16, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 16, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| May 16, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 1, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 1, 2022 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 7 | 0 | E |
| 2025 | 10 | 1 | G ▲ |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $10,985.
| Date | Type | Amount / length |
|---|---|---|
| Oct 31, 2025 | Fine | $10,985 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Arizona avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.52 | 3.97 | 3.95 | bottom 38% in Arizona; bottom 37% in the U.S. |
| Registered Nurse hours | 0.34 | 0.69 | 0.69 | bottom 8% in Arizona; bottom 14% in the U.S. |
| Weekend total nurse staffing | 3.17 | 3.50 | 3.50 | bottom 43% in Arizona; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.21 | 0.49 | 0.48 | bottom 11% in Arizona; bottom 13% in the U.S. |
| Total nursing staff turnover (%) | 46.3 | 45.2 | 45.8 | top 50% in Arizona; bottom 46% in the U.S. |
| RN turnover (%) | 47.6 | 43.6 | 42.9 | bottom 40% in Arizona; bottom 40% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.51, RN 0.34, weekend 3.16. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 09/25/2006 |
| Figueroa-Diaz, Vicente | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/01/2024 |
| Figueroa-Diaz, Vicente | Individual | ADP of the SNF | NOT APPLICABLE | 04/09/2025 |
| Fischbeck, Courtney | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2025 |
| Lorenz, Brian | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2014 |
| Lorenz, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2014 |
| Lorenz, Brian | Individual | ADP of the SNF | NOT APPLICABLE | 04/09/2025 |
| Murphy Health Holdings II LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Peterson, Forrest | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2019 |
| Sato, Ami | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Standard Bearer Healthcare Op LP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Agave Grove Post Acute | 2.3 mi | Glendale, AZ | ★★☆☆☆ | 2/5 | abuse |
| Life Care Center of North Glendale | 3.3 mi | Glendale, AZ | ★★★★★ | 4/5 | |
| Bella Vita Health and Rehabilitation Center | 3.7 mi | Glendale, AZ | ★★★☆☆ | 2/5 | abuse |
| Beatitudes Campus | 3.9 mi | Phoenix, AZ | ★★★☆☆ | 2/5 | |
| Coronado Healthcare Center | 3.9 mi | Phoenix, AZ | ★★★★★ | 4/5 | |
| Christian Care Nursing Center | 4.1 mi | Phoenix, AZ | ★★★★☆ | 4/5 | |
| The Rehabilitation Center at the Palazzo | 4.2 mi | Phoenix, AZ | ★★★★☆ | 3/5 | |
| North Mountain Medical and Rehabilitation Center | 5.2 mi | Phoenix, AZ | ★★★★★ | 5/5 | |
| Maryland Gardens Post Acute | 5.6 mi | Phoenix, AZ | ★★★☆☆ | 2/5 | abuse |
| Advanced Health Care of Glendale | 5.7 mi | Glendale, AZ | ★★★★★ | 4/5 | |
| Haven of Phoenix | 5.8 mi | Phoenix, AZ | ★★★☆☆ | 2/5 | abuse |
| Center at Arrowhead, LLC | 6.4 mi | Glendale, AZ | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 035159.