Home / Oregon / Milton Freewater
Milton Freewater Health and Rehabilitation
120 Elzora Street, Milton Freewater, OR 97862 · Umatilla County · (541) 938-3318
70 certified beds, about 32 residents a day · For profit - Corporation · Medicare and Medicaid since 1984
CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
2 of 5
Staffing
5 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385161 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on January 15, 2026, inspectors cited 5 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 26 health citations since April 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $8,278 in the last three years; the largest was $8,278, and the latest is dated August 7, 2025.
Nurses and nurse aides worked 5.34 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 1.16 of those hours.
34.1% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Evergreen Healthcare Group, an affiliated group of 43 nursing homes.
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.
904/23
806/24
408/25
501/26
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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
23D
2E
0F
Potential for minimal harm
0A
0B
0C
January 15, 2026Standard inspection, Complaint inspection · 5 citations
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review it was determined the facility failed to prevent drug diversion for 2 of 2 residents (#s 29 and 38) reviewed for misappropriation. This placed residents at risk for misappropriation of personal medications.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled residents (#1) reviewed for medication administration. This placed residents at risk for adverse side effects.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 2 sampled residents (#13) reviewed for urinary catheter received appropriate services when staff failed to ensure catheter tubing did not touch the floor. This failure placed residents at increased risk for urinary tract infections (UTIs) and its associated complications. The Centers for Disease Control and Prevention (CDC) website's 6/27/25 Catheter-associated Urinary Tract Infection (CAUTI) Basics revealed a CAUTI occurs when germs enter the urinary tract through a urinary catheter and cause infection. Heathcare workers and facilities can prevent CAUTIs and protect patients with proper infection control processes. [...]
- D Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 3 of 3 residents (#s 1, 8 and 22) reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from unnecessary antibiotic medications for 1 of 5 sampled residents (#22) reviewed for unnecessary medications. This placed residents at risk for the development of antibiotic-resistant organisms and other serious infections.
August 7, 2025Complaint inspection · 4 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, it was determined the facility failed to follow care planned interventions related to transfers for 1 of 3 sampled residents (#13) reviewed for safety. As a result, Resident 13 experienced an injury of unknown origin and internal bleeding, which required hospitalization and a blood transfusion.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse for 1 of 4 sampled residents (#11) reviewed for abuse. This placed residents at risk for abuse and psychosocial harm.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report an injury of unknown origin to the appropriate State agency within state mandated timelines for 1 of 3 sampled residents (#13) reviewed for accidents and falls.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, it was determined the facility failed to respond to a change of condition related to anticoagulant use for 1 of 3 sampled residents (#13) reviewed for change of condition. This placed residents at risk for adverse side effects of anticoagulant use.
June 28, 2024Standard inspection, Complaint inspection · 8 citations
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs.
- D Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were given the right to participate in the development of their person-centered care plan for 1 of 1 sampled resident (#2) reviewed for care planning. This placed residents at risk for not being involved in the care planning process.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately assess residents for falls for 1 of 1 sampled resident (#6) reviewed for falls. This placed residents at risk for inaccurate assessments and unmet care needs.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined that facility failed to develop and provide a summary of the baseline care plan for 3 of 8 sampled residents (#s 25, 26 and 180) reviewed for pain, nutrition and ADLs. This placed residents at risk for being uninformed of their plan of care.
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assist in vision care needs for 1 of 1 sampled resident (#2) reviewed for vision. This placed residents at risk for impaired vision.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in mobility for 1 of 2 sampled residents (#5) reviewed for rehabilitation services. This placed residents at risk for loss of mobility.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure records were accurate for 2 of 5 sampled residents (#s 6 and 10) reviewed for unnecessary medications. This placed residents at risk for inaccurate treatment.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 3 sampled residents (#s 7 and 17) reviewed for abuse. This placed residents at risk for abuse.
April 7, 2023Standard inspection · 9 citations
- E Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure care conferences were documented for 4 of 7 sampled residents (#s 10, 13, 20 and 21) reviewed for behaviors, unnecessary medications, care planning and nutrition. This placed residents at risk for incomplete records.
- D Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete quarterly care conferences and include residents and their representatives in their care planning process for 1 of 3 sampled residents (#22) reviewed for behaviors. This placed residents and their representatives at risk for not making their care needs and health care decisions known.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure misappropriation of medications for 2 of 2 sampled residents (#s 12 and 13) reviewed for misappropriation. This placed residents at risk for lack of medications.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure assessments accurately reflected the residents' status for 2 of 5 sampled residents (#s 21 and 22) reviewed for unnecessary medications. This placed residents at risk for inaccurate assessments.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a copy of a baseline care plan was provided to a resident for 1 of 3 sampled residents (#25) reviewed for dental services. This placed residents at risk for being uninformed about their care plans.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide and/or assess residents' need for bowel care and identify and provide care for a heart monitor for 3 of 7 sampled residents (#s 13, 128 and 228) reviewed for medications, change of condition and medical devices. This placed residents at risk for constipation and not receiving prescribed treatments.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure medications were ordered timely for 1 of 1 sampled resident (#3) reviewed for medication refills. This placed residents at risk for ineffective medication regimen.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to withhold a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#1) reviewed for unnecessary medications. This placed residents at risk for low blood pressure.
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide dental services for 1 of 3 sampled residents (#2) reviewed for dental care needs. This placed residents at risk for unmet dental needs.
Fire safety inspections
10 fire safety citations on file: 1 on January 15, 2026, 2 on June 28, 2024, 7 on April 7, 2023.
Every fire safety citation10 citations
- F Have generator or other power source capable of supplying service within 10 seconds.
- F Have simulated fire drills held at unexpected times.
- D Have properly installed electrical wiring and gas equipment.
- F Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have power receptacles that are properly grounded.
- D Provide a written emergency evacuation plan.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| August 7, 2025 | Fine | $8,278 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
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 | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.34 | 5.03 | 3.86 |
| Registered nurses | 1.16 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.69 | 4.51 | 3.42 |
| Nurse aides | 4.04 | ||
| Licensed practical nurses | 0.14 | ||
| Nursing staff turnover (share who left in a year) | 34.1% | 47.4% | 45.8% |
| Registered nurse turnover | 45.5% | 51.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.64 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 5.60 on weekdays and 4.69 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.64 in April to June 2025 to 5.34 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 | 5.34 | 1.16 | 5.60 | 4.69 | 4.4% | 0 of 90 | 32 |
| Oct to Dec 2025 | 5.90 | 1.20 | 6.13 | 5.34 | 3.6% | 0 of 92 | 29 |
| Jul to Sep 2025 | 5.42 | 1.09 | 5.68 | 4.74 | 0.6% | 0 of 92 | 31 |
| Apr to Jun 2025 | 4.64 | 1.06 | 4.89 | 3.99 | 4.9% | 0 of 91 | 31 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% 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 | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.6 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.8 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 5.6 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.0 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.7 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 18.7 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 27.7 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 18.0 | 16.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.4 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 2.4 | 1.8 |
Owners and operators
Legal business name: MILTON FREEWATER SNF OPERATIONS, LLC. CMS links this home to Evergreen Healthcare Group, a group of 43 nursing homes averaging 2.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Milton Freewater SNF Operations, LLC | Direct ownership interest | Organization | 08/31/2023 | |
| Pacific Northwest 12 Leased Operations Holdings LLC | Direct ownership interest | Organization | 08/31/2023 | |
| Ch Pnw 12 Holdings LLC | Indirect ownership interest | Organization | 08/31/2023 | |
| Couve Financial Services LLC | Indirect ownership interest | Organization | 08/31/2023 | |
| Couve Healthcare Consulting LLC | Indirect ownership interest | Organization | 08/31/2023 | |
| Freewater Oregon LLC | Indirect ownership interest | Organization | 08/31/2023 | |
| Pnw 12 Opco Management LLC | Indirect ownership interest | Organization | 08/31/2023 | |
| Pnw 12 SNF Consulting LLC | Indirect ownership interest | Organization | 08/31/2023 | |
| Witzcorp Pnw 12 LLC | Indirect ownership interest | Organization | 08/31/2023 | |
| Ashby, William | Indirect ownership interest | Individual | 08/31/2023 | |
| Chambers, Randy | Indirect ownership interest | Individual | 08/31/2023 | |
| Herzka, Yisroel | Indirect ownership interest | Individual | 08/31/2023 | |
| Hyde, Deidre | Indirect ownership interest | Individual | 08/31/2023 | |
| Odenthal, Jason | Indirect ownership interest | Individual | 08/31/2023 | |
| Spielman, Shimon | Indirect ownership interest | Individual | 08/31/2023 | |
| Yenowitz, Yitzchok | Indirect ownership interest | Individual | 08/31/2023 | |
| Odenthal, Jason | Managing control - governing body | Individual | 08/31/2023 | |
| Couve Financial Services LLC | Operational/managerial control | Organization | 08/31/2023 | |
| Couve Healthcare Consulting LLC | Operational/managerial control | Organization | 08/31/2023 | |
| Milton Freewater SNF Operations, LLC | Operational/managerial control | Organization | 08/31/2023 | |
| Pnw 12 Opco Management LLC | Operational/managerial control | Organization | 08/31/2023 | |
| Pnw 12 SNF Consulting LLC | Operational/managerial control | Organization | 08/31/2023 | |
| Ashby, William | Operational/managerial control | Individual | 08/31/2023 | |
| Chambers, Randy | Operational/managerial control | Individual | 08/31/2023 | |
| Hyde, Deidre | Operational/managerial control | Individual | 08/31/2023 | |
| Odenthal, Jason | Operational/managerial control | Individual | 08/31/2023 | |
| Spielman, Shimon | Operational/managerial control | Individual | 08/31/2023 | |
| Yenowitz, Yitzchok | Operational/managerial control | Individual | 08/31/2023 | |
| Couve Financial Services LLC | Adp of the SNF | Organization | 06/02/2025 | |
| Couve Healthcare Consulting LLC | Adp of the SNF | Organization | 06/02/2025 | |
| Freewater Oregon LLC | Adp of the SNF | Organization | 06/02/2025 | |
| Pnw 12 Opco Management LLC | Adp of the SNF | Organization | 06/02/2025 | |
| Pnw 12 SNF Consulting LLC | Adp of the SNF | Organization | 06/02/2025 | |
| Ashby, William | Adp of the SNF | Individual | 08/31/2023 | |
| Chambers, Randy | Adp of the SNF | Individual | 08/31/2023 | |
| Hyde, Deidre | Adp of the SNF | Individual | 08/31/2023 | |
| Odenthal, Jason | Adp of the SNF | Individual | 08/31/2023 | |
| Spielman, Shimon | Adp of the SNF | Individual | 08/31/2023 | |
| Yenowitz, Yitzchok | Adp of the SNF | Individual | 08/31/2023 |
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 8 problems in this area, most recently on January 15, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on June 28, 2024: "Ensure each resident receives an accurate assessment."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 5 problems in this area, most recently on January 15, 2026: "Protect each resident from the wrongful use of the resident's belongings or money."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on January 15, 2026: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
Other nursing homes nearby
- Regency at the Park College Place, 7.4 mi · 5 of 5 stars · 35 citations
- Park Manor Rehabilitation Ctr Walla Walla, 7.8 mi · 5 of 5 stars · 7 citations
- Washington State Walla Walla Veterans Home Walla Walla, 8.4 mi · 4 of 5 stars · 27 citations
- Washington Odd Fellows Home Walla Walla, 9.6 mi · 4 of 5 stars · 54 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Milton Freewater Health and Rehabilitation's Medicare star rating?
- CMS rates Milton Freewater Health and Rehabilitation 3 out of 5 stars overall, with 2 for health inspections, 5 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Milton Freewater Health and Rehabilitation get at its last inspection?
- 5 health deficiencies at the standard inspection on January 15, 2026. The Oregon average is 9.2.
- Has Milton Freewater Health and Rehabilitation been fined?
- Yes. CMS lists 1 fine totaling $8,278 in the last three years.
- Does Milton Freewater Health and Rehabilitation accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Milton Freewater Health and Rehabilitation?
- CMS lists 39 owners and managers, and links the home to Evergreen Healthcare Group. Legal business name: MILTON FREEWATER SNF OPERATIONS, 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.