Cycle 1
Health 2024-04-25 · Fire 2024-04-25
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Peoria, AZ
Freedom Plaza Care Center
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
13714 North Plaza Del Rio Blvd, Peoria, AZ
(623) 815-6100
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-12-15
CMS approved date
Coverage
Medicare
Participation flags
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
0.74
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.72
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
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
391
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0228
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.35
Baseline 20.42% · Performance 19.41% · Measure score 4.35 · Achievement 4.35 · Improvement 2.47
Healthcare-associated infections
10
Baseline 5.28% · Performance 4.34% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
7.75
Performance 32.00% · Measure score 7.75 · Achievement 7.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.23
Baseline 5.24 hours · Performance 4.85 hours · Measure score 6.23 · Achievement 6.23 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.1% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 374 · Observed rate 11.5% · Lower 95% interval 8.76% |
| Discharge to community | 73.08% |
50.57%
22.5 pts better
|
Better than the National Rate · Eligible stays 364 · Observed rate 69.23% · Lower 95% interval 67.95% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 284 · Denominator 284 |
| Falls with major injury | 0.35% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 284 |
| Discharge self-care score | 45.23% |
53.69%
8.5 pts worse
|
Numerator 109 · Denominator 241 |
| Discharge mobility score | 22.82% |
50.94%
28.1 pts worse
|
Numerator 55 · Denominator 241 |
| Pressure ulcers or injuries, new or worsened | 1.41% |
2.29%
0.9 pts better
|
Numerator 4 · Denominator 284 · Adjusted rate 1.69% |
| Healthcare-associated infections requiring hospitalization | 4.34% |
7.12%
2.8 pts better
|
Better than the National Rate · Eligible stays 225 · Observed rate 1.78% · Lower 95% interval 2.61% |
| Staff COVID-19 vaccination coverage | 8.12% |
8.2%
0.1 pts worse
|
Numerator 19 · Denominator 234 |
| Staff flu vaccination coverage | 20.56% |
42%
21.4 pts worse
|
Numerator 59 · Denominator 287 |
| Discharge function score | 31.12% |
56.45%
25.3 pts worse
|
Numerator 75 · Denominator 241 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 239 · Denominator 239 |
| Resident COVID-19 vaccinations up to date | 28% |
25.2%
2.8 pts better
|
Numerator 42 · Denominator 150 |
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 | 0.0% |
2.1%
2.1 pts better
|
3.3%
3.3 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 who have depressive symptoms | 5.1% |
4.2%
0.9 pts worse
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 9.5% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 15.1% |
5.3%
9.8 pts worse
|
5.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
20.5%
15.1 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
11.8%
9.3 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.1% · 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 need for help with daily activities has increased | 16.2% |
10.8%
5.4 pts worse
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 12.4% |
1.2%
11.2 pts worse
|
1.7%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 10.0% · Q3 12.5% · Q4 12.0% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.2% |
20.5%
7.3 pts better
|
19.8%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 29.3% · Q4 0.0% · 4Q avg 13.2% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.8%
0.9 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.3% · Q3 3.6% · Q4 1.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
91.1%
8.8 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
10.7%
About the same
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 9.6% · Expected 10.1% · 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 0.0% · Q2 0.0% · Q3 0.4% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.8% |
87.3%
12.5 pts better
|
79.7%
20.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
24.6%
3.4 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 26.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-11 · Fire 2023-01-11
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-11-12 · Fire 2021-11-12
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-25
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-06-26
E · Potential for more than minimal harm
2024-04-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-04-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-05-28
E · Potential for more than minimal harm
2021-11-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-03
E · Potential for more than minimal harm
2021-11-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-03
E · Potential for more than minimal harm
2021-11-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-11-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-01-03
E · Potential for more than minimal harm
2021-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-03
E · Potential for more than minimal harm
2021-11-12
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
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 2022-01-03
D · Potential for more than minimal harm
2021-11-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-01-03
D · Potential for more than minimal harm
2021-11-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-01-03
B · Minimal harm
2021-11-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-01-03
Penalties and ownership
What sits behind the stars
Ownership
Sun Health Freedom Plaza, LLC
5% Or Greater Direct Ownership Interest · Organization
Sun Health Services
5% Or Greater Indirect Ownership Interest · Organization
Fmc Arizona, LLC
Operational/Managerial Control · Organization
La Rue, Joseph
Operational/Managerial Control · Individual
Larman, Jai
Operational/Managerial Control · Individual
Lewis, Ian
Operational/Managerial Control · Individual
Makhija, Manoj
Operational/Managerial Control · Individual
Roskamp, Cheryl
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Peoria Post Acute And Rehabilitation
Peoria, AZ
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Boswell Transitional Care Of Cascadia
Sun City, AZ
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Sunview Respiratory And Rehabilitation
Youngtown, AZ
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out