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
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing
LPN hours / resident day
1.41
Licensed practical nurse staffing
Aide hours / resident day
2.54
Nurse aide staffing
Weekend hours
4.25
Weekend nurse staffing
RN turnover
22%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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