20 Reports
Inspection Report — Apr 28, 2026
Complaint Investigation
Date: Apr 28, 2026
Visit Reason
On-site complaint investigation of complaints 00167487 and 2995312 at a Nursing Care Institution, conducted 28 April 2026.
Complaint Details
The onsite complaint survey was conducted on April 29, 2026 and investigated complaints # 00167487 and # 2995312. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jan 27, 2026
Date: Jan 27, 2026
Visit Reason
On-site inspection of a Nursing Care Institution classified as 'Other' type, conducted 27 January 2026.
Findings
Two deficiencies were found related to kitchen appliance safety restraints and corridor door maintenance. The facility provided plans of correction for both deficiencies.
Deficiencies (2)
Cooking facilities safety — The kitchen appliances were observed on casters without any restraint chain or apparatus to prevent strain breakage of the gas connection, confirmed by the Director of Maintenance.
Corridor door maintenance — The facility failed to ensure patient corridor doors were in good working condition, which could cause harm to patients and staff during an emergency.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 13, 2026
Complaint Investigation
Date: Jan 13, 2026
Visit Reason
On-site complaint investigation of complaints 00153781, 00154023, 2278310, 2697098, 2698743, 2278314, and 2278309 at a Nursing Care Institution, conducted 13 January 2026.
Complaint Details
This complaint survey was conducted from January 13, 2026, to investigate complaints: 00153781, 00154023, 2278310, 2697098, 2698743, 2278314, and 2278309. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 7
Inspection Report — Nov 28, 2025
Complaint Investigation
Date: Nov 28, 2025
Visit Reason
On-site complaint investigation of complaints 00148879, 00148942, 2653018, 2653264, 2652179 and 2652406 at a Nursing Care Institution, conducted 28 November 2025.
Complaint Details
The onsite complaint survey was conducted on November 12, 2025 and investigated complaints #00148879 and 00148942. The onsite complaint survey was conducted on November 12, 2025 and investigated complaints #2653018, 2653264, 2652179 and 2652406. There were no deficiencies noted.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 6
Inspection Report — Nov 25, 2025
Annual Inspection
Date: Nov 25, 2025
Visit Reason
On-site complaint and annual compliance inspection of complaints 00147533, 2640367, and 2642070 at a Nursing Care Institution, conducted 15 October 2025.
Complaint Details
The onsite complaint survey was conducted on October 15, 2025 and investigated complaints #00147533, #2640367, and #2642070. There were no deficiencies noted.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 3
Inspection Report — Jun 25, 2025
Complaint Investigation
Date: Jun 25, 2025
Visit Reason
On-site complaint investigation of intakes AZ00171677, AZ00190992, AZ00224910, AZ00171676, AZ00190740 and AZ00190993 at a Nursing Care Institution, conducted 25 June 2025.
Complaint Details
A complaint survey was conducted on June 25, 2025 for the investigation of intakes #'s: AZ00171677, AZ00190992, AZ00224910, AZ00171676, AZ00190740 and AZ00190993. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 6
Inspection Report — Jun 3, 2025
Complaint Investigation
Date: Jun 3, 2025
Visit Reason
On-site complaint investigation of intake 00109089 and complaint AZ00223456 at a Nursing Care Institution, conducted 3 June 2025.
Complaint Details
A complaint survey was conducted on June 3, 2025 for the investigation of intakes #'s: 00109089. A complaint survey was conducted on June 3, 2025 for the investigation of intakes #'s: AZ00223456.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 15, 2025
Complaint Investigation
Date: Apr 15, 2025
Visit Reason
On-site complaint investigation of intake numbers 00126429, AZ00224141, and AZ00224154 at a Nursing Care Institution, conducted 15 April 2025.
Complaint Details
A complaint survey was conducted on April 15, 2025 for the investigation of intake #00126429, AZ00224141, and AZ00224154. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 3
Inspection Report — Feb 25, 2025
Complaint Investigation
Date: Feb 25, 2025
Visit Reason
On-site complaint investigation of intakes AZ00223023 and AZ00223385 at a Nursing Care Institution, conducted 25 February 2025.
Complaint Details
A complaint survey was conducted on February 25, 2025 for in the investigation of intakes #AZ00223023, AZ00223385. Federal comments also reference investigation of intakes #AZ00223023, AZ00223383. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Jan 24, 2025
Complaint Investigation
Date: Jan 24, 2025
Visit Reason
On-site complaint investigation of intakes AZ00221837 and AZ00221965 at a Nursing Care Institution, conducted 24 January 2025.
Complaint Details
A complaint survey was conducted on January 24, 2025 of intakes #AZ00221837 and AZ00221965. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jan 2, 2025
Complaint Investigation
Date: Jan 2, 2025
Visit Reason
On-site complaint investigation of intake AZ00220809 at a Nursing Care Institution, conducted 2 January 2025.
Complaint Details
A complaint survey was conducted on January 02, 2024 for the investigation of intake # AZ00220809. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Nov 20, 2024
Complaint Investigation
Date: Nov 20, 2024
Visit Reason
On-site complaint investigation of complaints AZ00218555 and AZ00218554 at a Nursing Care Institution, conducted 20 November 2024.
Complaint Details
The Complaint survey was conducted on November 20, 2024 with the investigation of the following complaints AZ00218555 and AZ00218554. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Oct 9, 2024
Complaint Investigation
Date: Oct 9, 2024
Visit Reason
On-site complaint investigation of intake numbers AZ00217019 and AZ00217018 at a Nursing Care Institution, conducted 8-9 October 2024.
Complaint Details
A complaint survey was conducted on October 8, 2024 through October 9, 2024 for the investigation of intake # AZ00217019 and intake # AZ00217018. There were no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Sep 17, 2024
Complaint Investigation
Date: Sep 17, 2024
Visit Reason
On-site complaint investigation of intakes AZ002156030 and AZ002156080 at a Nursing Care Institution, conducted 17 September 2024.
Complaint Details
The complaint survey was conducted on September 17, 2024, with the investigation of intake #s: AZ002156030, AZ002156080. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — May 8, 2024
Date: May 8, 2024
Visit Reason
On-site inspection of a Nursing Care Institution at Freedom Plaza Care Center conducted on 8 May 2024 as a recertification survey under the Life Safety Code 2012 Edition.
Findings
The inspection found four deficiencies related to emergency preparedness policies, fire protection and separation, portable fire extinguisher placement, and smoke barrier penetrations. The facility provided acceptable plans of correction for all deficiencies.
Deficiencies (4)
Based on review and interview, the facility failed to develop and implement emergency preparedness policies and procedures describing its role in providing care at alternate care sites under an 1135 waiver.
The facility failed to provide adequate fire protection and separation between the Assisted Living Center and the nursing home, including incomplete firewall separation in therapy areas.
NFPA 10 — The facility failed to provide a fire extinguisher within 50 feet of the generator, risking harm during an emergency.
NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.3.7.3 — The facility failed to seal penetrations in four smoke barriers, allowing smoke and heat to potentially spread during a fire.
Report Facts
Deficiencies cited: 4
Inspection Report — Apr 25, 2024
Annual Inspection
Date: Apr 25, 2024
Visit Reason
On-site complaint investigation of complaints AZ00207294, AZ00207062, AZ00205906, AZ00205239, AZ00200367, AZ00206318, AZ00204461, AZ00203848, AZ00207732 combined with an annual recertification survey at a Nursing Care Institution, conducted 22 to 25 April 2024.
Complaint Details
The recertification survey was conducted on April 22, 2024 through April 25, 2024 in conjunction with the investigation of complaints # AZ00207294, AZ00207062, AZ00205906, AZ00205239, AZ00200367, AZ00206318, AZ00204461, AZ00203848, AZ00207732. There were no deficiencies cited.
Findings
This inspection found no deficiencies or citations.
Report Facts
Complaints investigated: 9
Inspection Report — Oct 4, 2023
Complaint Investigation
Date: Oct 4, 2023
Visit Reason
On-site complaint investigation of complaints AZ00200907 and AZ00200905 at a Nursing Care Institution, conducted 22 September to 4 October 2023.
Complaint Details
The investigation of complaint #'s AZ00200907 and AZ00200905 was conducted 9/22/23-10/4/23. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Jul 24, 2023
Complaint Investigation
Date: Jul 24, 2023
Visit Reason
On-site complaint investigation of complaint AZ00197623 at a Nursing Care Institution, conducted 24 July 2023.
Complaint Details
The Complaint AZ00197623 was investigated on 7/24/23. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jan 11, 2023
Annual Inspection
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 — Nov 12, 2021
Routine
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
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 |
3 CMS Surveys
CMS Survey — Nov 12, 2021
Nov 12, 2021
CMS Survey — Jan 11, 2023
Jan 11, 2023
CMS Survey — Apr 25, 2024
Apr 25, 2024
Viewing
Loading inspection reports...
