Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
Complaint survey with no deficiencies cited for intakes AZ00171677 and AZ00190992.
Complaint Details
Investigation of intakes AZ00171677 and AZ00190992.
Findings
Complaint survey with no deficiencies cited for intakes AZ00171677 and AZ00190992.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
Complaint survey with no deficiencies cited for intake 00109089.
Complaint Details
Investigation of intake 00109089.
Findings
Complaint survey with no deficiencies cited for intake 00109089.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
Complaint survey with no deficiencies cited for intakes 00126429 and AZ00224141.
Complaint Details
Investigation of intakes 00126429 and AZ00224141.
Findings
Complaint survey with no deficiencies cited for intakes 00126429 and AZ00224141.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
Complaint survey with no deficiencies cited for intakes AZ00223023 and AZ00223385.
Complaint Details
Investigation of intakes AZ00223023 and AZ00223385.
Findings
Complaint survey with no deficiencies cited for intakes AZ00223023 and AZ00223385.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Jan 24, 2025
Visit Reason
Complaint survey with no deficiencies cited for intakes AZ00221837 and AZ00221965.
Complaint Details
Investigation of intakes AZ00221837 and AZ00221965.
Findings
Complaint survey with no deficiencies cited for intakes AZ00221837 and AZ00221965.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
Complaint survey with no deficiencies cited for intake AZ00220809.
Complaint Details
Investigation of intake AZ00220809.
Findings
Complaint survey with no deficiencies cited for intake AZ00220809.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Nov 20, 2024
Visit Reason
Complaint survey with no deficiencies cited for complaint AZ00218555.
Complaint Details
Investigation of complaint AZ00218555.
Findings
Complaint survey with no deficiencies cited for complaint AZ00218555.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
Complaint survey with no deficiencies cited for intake AZ00217019.
Complaint Details
Investigation of intake AZ00217019.
Findings
Complaint survey with no deficiencies cited for intake AZ00217019.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
Complaint survey with no deficiencies cited for intakes AZ002156030 and AZ002156080.
Complaint Details
Investigation of intakes AZ002156030 and AZ002156080.
Findings
Complaint survey with no deficiencies cited for intakes AZ002156030 and AZ002156080.
Inspection Report
Capacity: 111
Deficiencies: 4
Date: May 8, 2024
Visit Reason
Recertification survey with deficiencies related to emergency preparedness policies, fire protection, fire extinguishers, and smoke barrier construction.
Findings
Recertification survey with deficiencies related to emergency preparedness policies, fire protection, fire extinguishers, and smoke barrier construction.
Deficiencies (4)
Emergency preparedness policies and procedures not developed and implemented
Multiple Occupancies - Construction Type — inadequate fire protection and separation
Portable Fire Extinguishers — failure to provide extinguisher near generator
Subdivision of Building Spaces - Smoke Barrier Construction — failure to fill penetrations in smoke barriers
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Freedom Plaza Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Apr 22, 2024
Visit Reason
Recertification survey combined with complaint investigations with no deficiencies cited.
Complaint Details
Investigation of complaints AZ00207294, AZ00207062, AZ00205906, AZ00205239, AZ00200367, AZ00206318, AZ00204461, AZ00203848, AZ00207732.
Findings
Recertification survey combined with complaint investigations with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
Complaint investigation with no deficiencies cited for complaint AZ00200907.
Complaint Details
Investigation of complaint AZ00200907.
Findings
Complaint investigation with no deficiencies cited for complaint AZ00200907.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Jul 24, 2023
Visit Reason
Complaint investigation with no deficiencies cited for complaint AZ00197623.
Complaint Details
Investigation of complaint AZ00197623.
Findings
Complaint investigation with no deficiencies cited for complaint AZ00197623.
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 1
Date: Jan 11, 2023
Visit Reason
Compliance survey with one deficiency cited related to personnel record maintenance.
Complaint Details
Investigation of multiple complaints AZ00189473, AZ00189171, AZ00188603, AZ00182572, AZ00182573, AZ00185169, AZ00185170, AZ00183930, AZ00189337.
Findings
Compliance survey with one deficiency cited related to personnel record maintenance.
Deficiencies (1)
R9-10-406.F — Personnel record maintenance
Inspection Report
Capacity: 111
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
Recertification survey for Life Safety Code compliance with no deficiencies cited.
Findings
Recertification survey for Life Safety Code compliance with no deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
Annual inspection survey completed to assess compliance with health and safety regulations at Freedom Plaza Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 39
Deficiencies: 12
Date: Nov 12, 2021
Visit Reason
Routine inspection of Freedom Plaza Care Center to assess compliance with healthcare regulations including medication administration, abuse reporting, resident transfers, assessments, activities, infection control, staffing, and COVID-19 protocols.
Findings
The facility had multiple deficiencies including failure to consistently notify physicians of unavailable medications, failure to report verbal abuse allegations, failure to notify residents and representatives of transfers in writing, inaccurate Minimum Data Set assessments, inconsistent medication administration, failure to provide resident-centered activities, improper application of TED hose, inadequate pain management, incomplete nurse staffing postings, lapses in infection control hand hygiene, incomplete COVID-19 staff screening, and failure to timely notify residents and families of COVID-19 cases.
Deficiencies (12)
Failed to ensure physician was consistently notified when scheduled blood pressure medication was unavailable and not administered to resident #5.
Failed to report an allegation of verbal abuse for resident #120 to State Survey Agency and Adult Protective Services.
Failed to notify resident #4 and representative in writing of transfer to hospital and failed to notify Ombudsman.
Failed to ensure Minimum Data Set assessment was accurate for resident #22.
Failed to ensure scheduled blood pressure medication was consistently administered to resident #5.
Failed to provide ongoing resident-centered activities based on assessment and preferences for resident #220.
Failed to ensure resident #320 received treatment and care in accordance with orders related to application of TED hose.
Failed to post complete nursing staffing information daily including total scheduled and actual hours worked.
Failed to ensure medication error rate was less than 5%, with errors in administration of Aspirin and Vitamin D for residents #6 and #15.
Failed to ensure staff performed appropriate hand hygiene during meal service and interactions with residents.
Failed to ensure two staff members (#22 and #73) completed COVID-19 screening prior to or at beginning of shift.
Failed to ensure residents #2, #9, and #10 and their representatives were notified timely of new COVID-19 cases in the facility.
Report Facts
Medication error rate: 6.67
Census: 39
Medication doses not given: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #35 | Registered Nurse | Named in medication administration and medication error findings |
| Staff #43 | Licensed Practical Nurse | Named in medication administration and medication error findings |
| Staff #86 | Director of Nursing | Named in multiple findings including medication administration, transfer notification, and COVID-19 screening |
| Staff #56 | Activities Coordinator | Named in resident activities deficiency |
| Staff #71 | Certified Nursing Assistant | Named in infection control hand hygiene deficiency |
| Staff #3 | Licensed Practical Nurse | Named in medication administration and pain management findings |
| Staff #33 | Licensed Practical Nurse | Named in TED hose application deficiency |
| Staff #9 | Certified Nursing Assistant | Named in COVID-19 screening deficiency |
| Staff #22 | Server | Named in COVID-19 screening deficiency |
| Staff #73 | Housekeeper | Named in COVID-19 screening deficiency |
| Staff #96 | Registered Nurse | Named in medication error findings |
| Staff #129 | Omnicell Pharmacy Representative | Named in medication administration findings |
| Staff #10 | Registered Nurse | Named in medication administration findings |
| Staff #31 | Administrator | Named in COVID-19 screening and infection control findings |
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