Freedom Plaza Care Center
13714 North Plaza Del Rio Blvd, Peoria, AZ 85381 · Maricopa County · (623) 815-6100
111 certified beds, about 61 residents a day · For profit - Limited Liability company · Medicare since 1999
Last standard inspection more than 2 years ago Part of a continuing care retirement community Certified for Medicare
Overall
5 of 5
Health inspections
5 of 5
Staffing
5 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 035256 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 25, 2024, inspectors cited 0 health deficiencies (the Arizona average is 6.4, the national average 9.2).
None of its 12 health citations since November 2021 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.87 hours per resident per day, against 3.98 across Arizona and 3.86 nationally. Registered nurses accounted for 0.80 of those hours.
32.1% of nursing staff left within the year CMS measured (Arizona average 45.1%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1211/21
001/23
004/24
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
3E
0F
Potential for minimal harm
0A
1B
0C
April 25, 2024Standard inspection · 0 citations
January 11, 2023Standard inspection · 0 citations
November 12, 2021Standard inspection · 12 citations
- E Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure a scheduled blood pressure medication was consistently administered to one resident (#5). The sample size was 5. The deficient practice could result in medications not being administered to residents.
- E Provide and implement an infection prevention and control program.
Inspectors wroteObservations conducted of the dining room for hall 400: -On November 8, 2021 at 12:25 p.m., the Licensed Practical Nurse (LPN/staff #43) from hall 400 brought a resident into the dining room, placed the resident at the table and locked the wheelchair. Staff #43 then went to assist another resident. The LPN touched the resident on the shoulder, sat down at that residents table, touched the table cloth and one resident's silverware. The LPN was not observed to perform hand hygiene. -On November 9, 2021 at 1:15 p.m. during the lunch service, a Certified Nursing Assistant (CNA/staff #71) was observed to move from table to table delivering plates and beverages in the dining room. The CNA assisted residents in cutting food, touched silverware for several residents including two residents who subsequently used the same utensils. The CNA was not observed to perform hand hygiene. [...]
- E Report COVID19 data to residents and families.
Inspectors wroteBased on clinical record reviews, facility documentation, staff interview, policy review, the Centers for Disease Control and Prevention (CDC) guidance, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule, the facility failed to ensure three residents (#2, #9, and #10), their representatives, and families were informed of new COVID-19 cases occurring in the facility within the required time frame. The deficient practice would result in residents, their representatives and families not being aware of new COVID-19 cases and the actions implemented to reduce the risk of transmission. The census was 39.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was consistently notified when a scheduled blood pressure medication was unavailable and not administered to one resident (#5). The sample size was 5. The deficient practice could result in residents not receiving necessary blood pressure medications.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on closed clinical record review, staff interviews, and policy review, the facility failed to report an allegation of verbal abuse for one sampled resident (#120) to the State Survey Agency and to Adult Protective Services (APS). The deficient practice could result in further allegations of resident abuse not being reported.
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and review of policy and procedure, the facility failed to notify one resident (#4) and the resident's representative of the transfer or discharge and the reasons for the move in writing, and send a copy of the notice to the Office of the State Long Term Care Ombudsman. The sample size was 3. The deficient practice could result in the resident/resident representative and/or the Ombudsman not being aware of the transfer and reason for transfer.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for one resident (#22). The sample size was 12. The deficient practice could result in inaccurate discharge tracking information.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on clinical record review, facility document, staff interviews, and facility policy and procedures, the facility failed to provide an ongoing resident centered activities program based on the comprehensive assessment, care plan, and resident's preferences for one of two sampled residents (#220). The deficient practice could result in residents not participating in activities which could impact their mental and social well-being.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and review of policy and procedures, the facility failed to ensure one sampled resident (#320) received treatment and care in accordance with professional standards of practice related to the application of Thrombo-Embolus Deterrent (TED) hose as ordered. The census was 39. The deficient practice could result in a lack of proper care being provided to residents.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure thorough pain management was consistently provided to one sampled resident (#2). The census was 39. The deficient practice could result in residents' pain not being addressed.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, clinical record reviews, staff interviews, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two of five sampled residents (#6 and #15). The medication error rate was 6.67%. The facility census was 39 residents. The deficient practice could result in additional medication errors.
- B Post nurse staffing information every day.
Inspectors wroteBased on observations, facility documents, staff interviews, and policy review, the facility failed to ensure nursing staffing information was complete and posted on a daily basis. The deficient practice resulted in information not being readily available to residents and visitors.
Fire safety inspections
11 fire safety citations on file: 4 on April 25, 2024, 7 on November 12, 2021.
Every fire safety citation11 citations
- E Install a two-hour-resistant firewall separation.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D Establish roles under a Waiver declared by secretary.
- E Inspect, test, and maintain automatic sprinkler systems.
- E Install corridor and hallway doors that block smoke.
- E Have properly installed electrical wiring and gas equipment.
- D Have properly installed hallway dispensers for alcohol-based hand rub.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
- D Have generator or other power source capable of supplying service within 10 seconds.
- D Have proper medical gas storage and administration areas.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Arizona | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.87 | 3.98 | 3.86 |
| Registered nurses | 0.80 | 0.70 | 0.69 |
| All nursing staff on weekends | 4.31 | 3.51 | 3.42 |
| Nurse aides | 2.57 | ||
| Licensed practical nurses | 1.51 | ||
| Nursing staff turnover (share who left in a year) | 32.1% | 45.1% | 45.8% |
| Registered nurse turnover | 42.9% | 43.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.74 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.10 on weekdays and 4.31 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.73 in April to June 2025 to 4.87 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.87 | 0.80 | 5.10 | 4.31 | 0.0% | 0 of 90 | 61 |
| Oct to Dec 2025 | 4.72 | 0.76 | 4.89 | 4.26 | 0.0% | 0 of 92 | 61 |
| Jul to Sep 2025 | 4.69 | 0.74 | 4.86 | 4.25 | 0.0% | 0 of 92 | 60 |
| Apr to Jun 2025 | 4.73 | 0.83 | 4.91 | 4.29 | 0.0% | 0 of 91 | 61 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Arizona, Jan to Mar 2026 | 3.87 | 0.63 | 4.05 | 3.43 | 3.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Arizona | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 14.3 | 10.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 11.8 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.0 | 2.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.4 | 1.2 | 1.6 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.3 | 4.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 22.9 | 10.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 26.8 | 23.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.3 | 10.4 | 12.0 |
Owners and operators
Legal business name: FREEDOM PLAZA OPERATING COMPANY LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Sun Health Freedom Plaza, LLC | 5% or greater direct ownership interest | Organization | 100% | 12/20/2024 |
| Sun Health Services | 5% or greater indirect ownership interest | Organization | 100% | 04/04/2018 |
| Cavanaugh-Marsh, Mary | Managing control - governing body | Individual | 01/01/2025 | |
| Gilstrap, Greg | Managing control - governing body | Individual | 01/01/2025 | |
| Haskell, Cornelius | Managing control - governing body | Individual | 01/01/2025 | |
| Hoffman, Sintra | Managing control - governing body | Individual | 01/01/2025 | |
| Kovala, Irene | Managing control - governing body | Individual | 01/01/2025 | |
| La Rue, Joseph | Managing control - governing body | Individual | 12/20/2024 | |
| Lancaster, Lewis | Managing control - governing body | Individual | 01/01/2025 | |
| Marrer, Gary | Managing control - governing body | Individual | 01/01/2025 | |
| Orcutt, Herman | Managing control - governing body | Individual | 01/01/2025 | |
| Orlopp, Sharon | Managing control - governing body | Individual | 01/01/2025 | |
| Reifsteck, Mark | Managing control - governing body | Individual | 01/01/2025 | |
| Rivera, Rey | Managing control - governing body | Individual | 01/01/2025 | |
| Solomon, Gerald | Managing control - governing body | Individual | 01/01/2025 | |
| Fmc Arizona, LLC | Operational/managerial control | Organization | 04/01/2018 | |
| La Rue, Joseph | Operational/managerial control | Individual | 12/20/2024 | |
| Larman, Jai | Operational/managerial control | Individual | 04/04/2018 | |
| Lewis, Ian | Operational/managerial control | Individual | 05/29/2022 | |
| Makhija, Manoj | Operational/managerial control | Individual | 04/04/2018 | |
| Roskamp, Cheryl | Operational/managerial control | Individual | 04/04/2018 | |
| Casino, Marianne | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/30/2026 | |
| Francese, Arsenio | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/30/2026 | |
| Roskamp, Ruth | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/30/2026 | |
| Stringer, Thomas | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/30/2026 | |
| Suckiel, Jennifer | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/30/2026 | |
| Fmc Arizona, LLC | Adp of the SNF | Organization | 04/10/2025 | |
| Sun Health Freedom Plaza, LLC | Adp of the SNF | Organization | 12/20/2025 | |
| Larman, Jai | Adp of the SNF | Individual | 04/04/2018 | |
| Lewis, Ian | Adp of the SNF | Individual | 05/29/2022 | |
| Makhija, Manoj | Adp of the SNF | Individual | 04/04/2018 | |
| Roskamp, Cheryl | Adp of the SNF | Individual | 04/04/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on November 12, 2021: "Provide activities to meet all resident's needs."
- When is the care plan meeting, and can family attend it?Inspectors cited 2 problems in this area, most recently on November 12, 2021: "Ensure services provided by the nursing facility meet professional standards of quality."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on November 12, 2021: "Provide and implement an infection prevention and control program."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 2 problems in this area, most recently on November 12, 2021: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
Other nursing homes nearby
- Peoria Post Acute and Rehabilitation Peoria, 0.3 mi · 4 of 5 stars · 8 citations
- Boswell Transitional Care of Cascadia Sun City, 1.8 mi · 5 of 5 stars · 10 citations
- Sunview Respiratory and Rehabilitation Youngtown, 2.5 mi · 2 of 5 stars · 18 citations
- Immanuel Campus of Care Peoria, 2.5 mi · 3 of 5 stars · 32 citations
- Az - Rio Vista Post Acute and Rehabilitation Peoria, 3.1 mi · 5 of 5 stars · 14 citations
- Center at Arrowhead, LLC Glendale, 3.2 mi · 5 of 5 stars · 13 citations
- Sun City Post Acute Sun City, 3.3 mi · 4 of 5 stars · 33 citations
- Advanced Health Care of Glendale Glendale, 4 mi · 3 of 5 stars · 9 citations
Arizona contacts for a concern about a nursing home
These are the official offices in Arizona. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Arizona Department of Health Services, Long Term Care Facilities Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- State inspection reports: AZ Care Check, where Arizona publishes its own records on licensed homes.
Common questions
- What is Freedom Plaza Care Center's Medicare star rating?
- CMS rates Freedom Plaza Care Center 5 out of 5 stars overall, with 5 for health inspections, 5 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Freedom Plaza Care Center get at its last inspection?
- 0 health deficiencies at the standard inspection on April 25, 2024. The Arizona average is 6.4.
- Has Freedom Plaza Care Center been fined?
- CMS lists no fines in the last three years.
- Does Freedom Plaza Care Center accept Medicaid?
- CMS lists it as "Medicare", so it is not certified for Medicaid.
- Who owns Freedom Plaza Care Center?
- CMS lists 32 owners and managers. Legal business name: FREEDOM PLAZA OPERATING COMPANY LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.