Cycle 1
Health 2025-05-16 · Fire 2025-05-16
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Glendale, AZ
Horizon Post Acute And Rehabilitation Center
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4704 West Diana Avenue, Glendale, AZ
(623) 247-3949
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
196
Certified beds
Average residents
140
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-04-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,338
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.23
Baseline 21.07% · Performance 19.01% · Measure score 5.23 · Achievement 5.23 · Improvement 4.60
Healthcare-associated infections
3.85
Baseline 7.45% · Performance 6.68% · Measure score 3.85 · Achievement 3.85 · Improvement 2.62
Total nurse turnover
2.63
Baseline 53.46% · Performance 52.94% · Measure score 2.63 · Achievement 2.63 · Improvement 0
Adjusted total nurse staffing
1.59
Baseline 3.31 hours · Performance 3.53 hours · Measure score 1.59 · Achievement 1.59 · Improvement 0.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.25% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 9.52% · Lower 95% interval 7.01% |
| Discharge to community | 61.22% |
50.57%
10.6 pts better
|
Better than the National Rate · Eligible stays 63 · Observed rate 57.14% · Lower 95% interval 50.99% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 112 · Denominator 112 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 112 |
| Discharge self-care score | 60.66% |
53.69%
7 pts better
|
Numerator 37 · Denominator 61 |
| Discharge mobility score | 54.1% |
50.94%
3.2 pts better
|
Numerator 33 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 0.89% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 112 · Adjusted rate 0.78% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 218 |
| Staff flu vaccination coverage | 23.94% |
42%
18.1 pts worse
|
Numerator 51 · Denominator 213 |
| Discharge function score | 68.85% |
56.45%
12.4 pts better
|
Numerator 42 · Denominator 61 |
| Transfer of health information to provider | 98.61% |
95.95%
2.7 pts better
|
Numerator 71 · Denominator 72 |
| Transfer of health information to patient | 72.41% |
96.28%
23.9 pts worse
|
Numerator 21 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 20.24% |
25.2%
5 pts worse
|
Numerator 17 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.1%
1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 2.2% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.2%
3.9 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.3%
3.2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.7% · Q3 1.2% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
20.5%
5 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 28.2% · Q3 28.2% · Q4 21.8% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
11.8%
2.9 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 8.1% · Q3 6.8% · Q4 7.5% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.1% |
14.5%
5.6 pts worse
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
10.8%
1.4 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 6.3% · Q3 10.3% · Q4 9.9% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 2.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
20.5%
1.4 pts better
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 29.1% · Q3 13.5% · Q4 16.9% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.8%
0.5 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.5% · Q3 6.2% · Q4 3.4% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.1%
8.6 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.8% · Q2 99.5% · Q3 99.4% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
10.7%
4.7 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 6.2% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.1%
0.9 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
87.3%
9.9 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
24.6%
0.1 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 24.6% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-04-01 · Fire 2022-04-01
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-20
E · Potential for more than minimal harm
2023-06-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-20
D · Potential for more than minimal harm
2022-04-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-05
Inspection history
Recent health citations
G · Actual harm
2025-10-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-07-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-07-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-06-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-30
E · Potential for more than minimal harm
2022-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-01
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-04-01
D · Potential for more than minimal harm
2022-04-01
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-04-01
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-05-20
Penalties and ownership
What sits behind the stars
Ownership
Bandera Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fischbeck, Courtney
Corporate Officer · Individual
Lorenz, Brian
Operational/Managerial Control · Individual
Peterson, Forrest
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Providence Place At Glencroft
Glendale, AZ
2-star overall rating with 2-star inspections with abuse icon flag with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of North Glendale
Glendale, AZ
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Bella Vita Health And Rehabilitation Center
Glendale, AZ
3-star overall rating with 2-star inspections with abuse icon flag with $12,735 in total fines with 10 recent health deficiencies
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