Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
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
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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