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Milton Freewater Health And Rehabilitation

120 Elzora Street, Milton Freewater, OR 97862 · For profit - Corporation · 70 certified beds · (541) 938-3318 Medicare & Medicaid certified

Call the home — (541) 938-3318 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Jan 20261 actual-harm citation$8,278 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jan 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-08-07)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
633 W Tietan St · (800) 511-8940 · Call to confirm hours
Pharmacy
1700 Se Meadowbrook Blvd · (509) 525-3626 · Call to confirm hours
Grocery
Supermex<0.1 mi
21 N Columbia St · (541) 938-4444 · Call to confirm hours
Park
200 De Haven St · Typically dawn to dusk
Place of worship
102 S Main St · (317) 727-8957

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.6%14.9%15.4%better
Long-stay residents who lose too much weight1.2%4.7%5.4%better
Long-stay residents with a catheter left in their bladder1.8%1.4%0.9%worse
Long-stay residents with a urinary tract infection5.6%2.0%2.0%worse
Long-stay residents with depressive symptoms2.4%4.9%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.0%2.4%3.3%better
Long-stay residents on antianxiety or hypnotic medication11.7%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine91.3%95.2%95.3%typical
Long-stay residents with pressure ulcers2.7%5.8%4.7%better
Long-stay residents with worsening bladder/bowel control14.6%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.7%13.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine60.6%81.2%79.4%worse
Short-stay residents rehospitalized after admission27.7%21.4%22.6%worse
Short-stay residents with an outpatient ER visit18.0%16.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.351.481.67worse
Long-stay outpatient ER visits per 1,000 resident days1.602.351.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

30.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

30.1%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
30.9%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 30.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF30.1%CMS range 22.4–41.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.1–14.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge30.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge23.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge28.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 4.6–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.16
RN hours/ resident / day
0.14
LPN hours/ resident / day
4.04
Aide hours/ resident / day
5.34
Total nurse hours/ resident / day
0.79
RN hoursweekends
34.1%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 31.8 residents a day — about 45% occupied, or roughly 38 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.16 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.04 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.69 hrs/resident/day on weekends vs 5.60 on weekdays — 16% thinner on weekends. RN hours go from 1.32 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2026-01-15)
7
at the previous standard inspection (2024-06-28)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2025-08-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a mechanical lift (Hoyer sling). On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 received an injury of unknown origin on her/his chest area and the resident experienced…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include:A facility policy regarding misappropriation dated 3/2025 stated the following:Each resident has the right to be free from misappropriation of resident property.Misappropriation of resident property includes diversion of a resident's medications for staff use or personal gain.1. Resident 38 was admitted to the facility in 2/2025 with diagnoses including loss of a lower extremity below the knee as result of frost bite.A 10/22/25 Physician Order stated hydrocodone-acetaminophen 5-325 mg to be provided as needed to address Resident 38's pain.An 11/11/25 Quarterly MDS revealed Resident 28 had normal cognitive function.Review of Resident 38's 11/2025 MAR revealed Resident 38 was documented as having received four doses of hydrocodone-acetaminophen at the following times on 11/20/25: 1:38 AM, 6:56 AM, 7:00 PM, and 11:30 PM.An…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-01-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include:Resident 1 was admitted to the facility in 9/2023 with diagnoses including pneumonia (an infection of the lungs) and unspecified convulsions.Resident 1's 11/24/25 Annual MDS indicated the resident was cognitively intact.Resident 1's 10/2025 MAR indicated the resident was to have levetiracetam (an anticonvulsant) twice a day for unspecified convulsions. Review of Resident 1's medical record revealed the following laboratory order:- 10/4/25 levetiracetam level for two days, must be done before resident takes morning dose. Review of Resident 1's 10/2025 MAR revealed she/he did not receive levetiracetam on 10/4/25, 10/5/25 and 10/6/25. Medication administration resumed on 10/7/25.The Facility's investigation dated 10/6/25 included the following:- On 10/6/25 it was noted Resident 1's levetiracetam was not active on her/his MAR.- Resident 1 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-01-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. The CDC's undated Indwelling Urinary Catheter Insertion and Maintenance Guide instructed urine bags to be kept off the floor and for staff to incorporate observation of urinary catheter and bag into routine rounds. Resident 13 was admitted to the facility in 6/2023 with diagnoses including presence of urogenital implants (having artificial devices in the urinary or reproductive organs,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include:1. Resident 8 was admitted to the facility in 12/2025 with diagnoses including colon cancer. Resident 8's 12/25/25 admission MDS revealed the resident was cognitively intact.Resident 8's 1/12/26 Care Plan indicated the resident was to be offered a shower each day during dayshift and she/he required assistance from two staff for showers. A review of Resident 8's Bathing Task Log from 12/20/25 to 1/13/26 revealed bathing activity did not occur on 12/20/25, 12/28/25, 1/2/26, 1/4/26, 1/6/26, 1/12/26 and 1/13/26. On 1/13/26 at 11:13 AM, Staff 14 (CNA) stated she worked dayshift at the facility, and they were short-staffed during her shift today. Staff 14 stated on days when they were short staffed, she was not able to complete all of her assigned responsibilities, including…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: The facility's 3/2018 Antimicrobial Stewardship Program Policy directed the following:-Applicable SBAR (Situation, Background, Assessment and Recommendation, a structured communication tool used by healthcare professionals to quickly and effectively convey critical patient information) tools are utilized to guide clinicians in the evaluation of clinical signs and symptoms potentially indicative of infection. -The clinical rationale to support the use of antibiotics, if using outside current clinical guidelines, is to be documented.-Communication with the resident and/or resident representative regarding the treatment plan and appropriate use of antibiotics is to be documented. -The DNS or IP is to collaborate with providers…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: The facility's Abuse Policy, updated in 3/2025, defined abuse as the willful infliction of injury with resulting physical harm, pain or mental anguish. Physical abuse was defined as hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing and shoving.Resident 10 admitted to the facility in 2018 with diagnoses including stroke and dysphagia (inability to swallow). Resident 10's MDS Quarterly dated 11/7/24 revealed a BIMS score of 99, indicating the assessment could not be completed. Resident 10's Care Plan revised on 12/29/24, revealed she/he had verbal and physical aggression toward others and behaviors such as pulling or knocking things off walls and counters and unsafe behaviors during mealtime. Care plan interventions included providing distractions, to monitor and cue the resident at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-07 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a Hoyer sling. On 7/29/25 and 7/30/25, two public complaints were received by the State Survey Agency (SSA) which stated Resident 13 had received an injury of unknown origin on her/his chest area and the resident experienced significant bruising, swelling at the chest area and was not sent to the hospital for several days…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: According to Drugs.com https://www.drugs.com/, serious side effects of anticoagulant medication include bleeding, with common adverse reactions including anemia, hemorrhage, and nausea.Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 13's care plan dated 7/13/25 revealed she/he was completely dependent for transfers and required a two person assist with a mechanical lift (Hoyer sling). The care plan also indicated the resident received an anticoagulant…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-28 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: On 6/23/24 the facility had a census of 26 residents. On 6/27/24, Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 13; -Required one or two-person extensive or total assistance for bathing: 21; -Required one or two-person extensive or total assistance for toileting: 18; -Required one or two-person extensive or total assistance for dressing: 22; -Required two person assistance at all times for all care: 3; -Had behavioral healthcare needs which required monitoring: 19; -Were at risk for elopement: 5. Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 11:15 PM revealed multiple times when no CNA staff were visualized in the hallways for up to 30 minutes. On 6/23/24 at 12:34 PM, Resident 2 stated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-28 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Resident 2 was admitted to the facility in 4/2023 with diagnoses including major depression and repeated falls. A review of Resident 2's health record revealed Resident 2 had not had a care conference completed since 11/9/23. A review of Resident 2's care plan revealed on 2/7/24, 3/5/24, 3/6/24 and 5/10/24, Resident 2's care plan was updated. On 6/23/24 at 12:36 PM, 6/24/24 at 11:55 AM, and 6/26/24 at 9:09 AM, Resident 2 stated with dissatisfaction, her/his most recent care conference was sometime last year. Resident 2 stated it was important for her/him to be involved in her/his care planning process and other residents participated regularly in care conferences so she/he did not understand why she/he had not had a care conference since last…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-06-28 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based 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. Findings include: Resident 6 was admitted to the facility in 10/2023 with diagnoses including dementia. The 3/28/24 Quarterly MDS indicated Resident 6 had one fall with major injury since her/his prior MDS assessment on 1/3/24. On 6/24/24 at 2:57 PM Staff 2 (DNS) stated Resident 6 had no falls since her/his prior MDS assessment on 1/3/24 and the resident's 3/28/24 Quarterly MDS, fall section, was inaccurate.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-28 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Resident 25 was admitted to the facility in 5/2024, with diagnoses including dementia without behavioral disturbances. Review of the Resident 25's health record indicated no evidence the facility provided a written summary of the baseline care plan to the resident or their representative. During an interview with Staff 2 (DNS) on 6/27/24 at 4:23 PM, she stated she did not know if a summary of the baseline care plan was provided to the resident. 2. Resident 180 was admitted to the facility in 6/2024, with diagnoses including compression fracture (occurs when one or more bones in the spine weaken and crumple). Review of Resident 180's health record indicated that a baseline care plan was not developed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-28 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Finding include: Resident 2 was admitted to the facility in 4/2023 with diagnoses including major depression and repeated falls. A 12/6/23 Physician Order indicated Resident 6 was referred for an eye examination due to visual changes and double vision. The 5/1/24 Quarterly MDS indicated Resident 2 had no impaired cognitive functioning and the resident wore glasses. A review of Resident 2's heath record revealed no evidence an eye examination was discussed with the resident, scheduled or completed. Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 4:30 PM revealed Resident 2 was not wearing glasses. On 6/23/24 at 12:40 PM, Resident 2 stated she/he was supposed to wear glasses and asked for glasses several months ago but nobody followed up. On 6/27/24 at 10:50 AM, Staff 2 (DNS) confirmed there was no evidence in Resident 2's health record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident 5 was admitted to the facility in 12/2022 with age-related debility (weakness). Resident 5's 6/14/24 PT Discharge Summary indicated the resident was discharged from PT services on 6/14/24. Resident 5's current Walk Daily Program task indicated Resident 5 was to be walked by CNA staff from her/his room to the nursing station and back using a front wheeled walker every day before lunch. A review of Resident 5's health record revealed no evidence the resident was walked by staff from her/his room to the nursing station and back on any days since Resident 5 was discharged from PT services. Observations from 6/23/24 through 6/27/24 between the hours of 8:00 AM and 11:15 PM revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: 1. Resident 6 was admitted to the facility in 10/2023 with diagnoses including hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Resident 6's 10/3/23 Physician Order indicated the resident was to receive levothyroxine (medication to treat hypothyroidism) one time a day to be given alone before breakfast. Resident 6's 5/2024 MAR revealed no documentation the resident's levothyroxine was administered on 5/6 and 5/30. On 6/26/24 at 1:53 PM, Staff 2 (DNS) stated the same nurse worked on 5/6/24 and 5/30/24 and the nurse administered Resident 6's levothyroxine on both days but did not document that he administered the medication because he was distracted during change of shift. 2. Resident 10 was admitted to the facility in 8/2021 with diagnoses including stomach ulcer. Resident 10's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: 1. Resident 7 was admitted to the facility in 6/2018, with diagnoses including dementia with behavior disturbances. Resident 7's 9/1/23 Care Plan indicated she/he had physical and verbal aggressive behaviors with instructions to intervene if this behavior escalated. Resident 17 was admitted to the facility in 3/2023, with diagnoses including hemiplegia (limited motor control of one side of the body). A 9/21/23 BIMs indicated Resident 17 had normal cognitive function. Resident 17 exhibited physical and verbal aggressive behaviors as indicated by her/his 9/1/23 care plan. Interventions included to intervene when the resident displayed these behaviors. On 11/3/23 a FRI was received by the State Survey Agency (SSA) which reported Resident 7 disturbed Resident 17's personal item which resulted in Resident 17…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-07 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: 1. Resident 13 was admitted to the facility in 2020 with diagnoses including chronic lung disease. A 2/16/23 Care Conference Form revealed the resident's weight was filled out and the resident's activity status was addressed. The sections of the form to indicate if the resident or resident's responsible party attended or was invited, who attended from the facility and if there were any identified concerns from the resident or responsible party were blank. The nursing summary, dietary summary, social services summary, therapy summary and follow up sections were also blank. On 4/6/23 at 10:31 AM Staff 6 (Social Services) stated the resident's care conference was done but she did not yet transcribe all the notes into the resident's record. 2. Resident 10 was admitted to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-07 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — the official record, unedited, may be distressing

    Based 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. Findings include: Resident 22 was admitted to the facility in 9/2022 with diagnoses including dementia and anxiety. Review of Resident 22's medical record revealed the resident's last care conference was completed on 11/10/22. There was no indication a care conference was held between 12/2022 and 4/2023. On 4/5/23 at 5:08 PM Staff 6 (Social Services) acknowledged Resident 22 and her/his representative did not have a care conference since November of 2022. She stated a busy workload and time constraints caused her to fall behind on scheduling and completing resident care conferences.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-07 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Resident 12 was admitted to the facility in 2021 with diagnoses including diabetes. Resident 13 was admitted to the facility in 2020 with diagnoses including an irregular heart beat. Resident 3 was admitted to the facility in 2019 with diagnoses including diabetes and a history of blood clots. Review of a 2/24/23 FRI and associated investigation revealed on 2/24/23 the facility identified Resident 3 did not have her/his apixaban (blood thinner) or metformin (treats diabetes) available in the medication cart. Residents with the same medications and dosages were identified. The pharmacy ran a report and the facility determined Resident 12 was short one metformin and Resident 13 was short one apixaban. The facility provided Resident 12 and Resident 13 a full 30 day supply of medications and ordered Resident 3…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-04-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: 1. Resident 21 was admitted to the facility in 9/2022 with diagnoses including depression and vascular dementia. Resident 21's 3/3/23 quarterly MDS indicated the resident received an anticoagulant medication (Section N: Medications - N0410 Medication Received) and received antipsychotic medications on a routine basis (Section N: Medications - N0450 Antipsychotic Medication Review). Review of Resident 21's medical record revealed the resident did not have orders for and did not receive an anticoagulant medication or an antipsychotic medication. On 4/6/23 at 10:02 AM Staff 4 (MDS Coordinator/RNCM) verified Resident 21 did not have orders for and did not receive an anticoagulant medication or antipsychotic medication and confirmed the resident's 3/3/23 quarterly MDS was inaccurately coded. 2.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-07 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — the official record, unedited, may be distressing

    Based 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. Findings include: Resident 25 was admitted to the facility 3/9/23 with diagnoses including UTI. Resident 25's 3/14/23 MDS indicated she/he was cognitively intact. Review of the resident's record revealed no evidence Resident 25 was provided a copy of her/his baseline care plan. On 4/3/23 at 12:16 PM Resident 25 stated the facility did not review the care plan with her/him. On 4/5/23 at 1:18 PM Staff 4 (MDS Coordinator/RNCM) stated the facility was to review baseline care plans with residents and provide a copy. If the resident declined a copy it was documented in the resident's record. A request was made to Staff 4 to provide documentation to verify Resident 25's baseline care plan was offered. No additional information was provided.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: 1. Resident 13 was re-admitted to the facility in 2022 with diagnoses including repair of a hip fracture. Review of a 2/17/23 quarterly MDS revealed Resident 13 was moderately cognitively impaired and required extensive assistance from two staff for toileting and transfers. Review of the resident's 3/2023 and 4/2023 bowel report revealed Resident 13 had a bowel movement on 3/22/23. Resident 13 did not have another bowel movement until 3/27/23, five days later. The resident's next documented bowel movement after 3/27/23 was on 4/4/23, eight days later. Review of the resident's 3/2023 MAR revealed the resident was to be administered Senna (laxative) PRN constipation and/or polyethylene…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Resident 3 was admitted to the facility in 2019 with diagnoses including diabetes and a history of blood clots. A 2/24/23 FRI and associated investigation revealed on 2/24/23 the facility identified Resident 3 did not have her/his apixaban (blood thinner) or metformin (treats diabetes) available in the medication cart. Resident 3's 2/2023 MARs revealed there were no missed medication administrations. On 4/4/23 at 7:52 AM Staff 13 (CMA) stated on one occasion she borrowed medications from other residents when Resident 3 ran out of medications. She did not recall who she borrowed the medications from but stated it was the same medication and the the same dosage. On 4/4/23 at 10:18 AM Staff 1 (Interim Administrator) stated during a routine Quality Assurance (QA) audit they found Resident 3's apixaban and metformin were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-04-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Resident 1 was admitted to the facility in 7/2013 with diagnoses including hypertension (high blood pressure). Physician orders from 10/18/22 for metoprolol tartrate stated Give 12.5 mg orally two times a day related to essential hypertension. Hold for [systolic blood pressure (SBP; upper blood pressure measurement)] <110. Review of Resident 1's MAR from 3/2023 revealed she/he received metoprolol tartrate outside of physician ordered parameters of SBP on: - 3/5/23 morning administration. SBP was 104. - 3/5/23 evening administration. SBP was 104. - 3/15/23 evening administration. SBP was 102. - 3/24/23 evening administration. SBP was 102. - 3/25/23 morning administration. SBP was 102. - 3/30/23 evening administration. SBP was 102. On 4/5/23 at 5:05 PM Staff 7 (RN) confirmed metoprolol…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-07 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Resident 2 was admitted to the facility in 8/2021 with diagnoses including stroke. On 4/3/23 at 4:15 PM Resident 2 was observed to have several damaged lower teeth which appeared jagged and dark. She/he reported, My lower teeth are gone mostly. Last time I saw a dentist was three years ago. Resident 2's current signed physician orders (dated 2/10/23) provided for her/him to have a consult and treatment for dental work as indicated. Resident 2's most recent comprehensive MDS assessment and CAAs (dated 6/16/22) indicated no obvious or likely cavities or broken natural teeth. The CAA worksheet revealed the resident's cognitive deficit contributed to her/his dental problems. The assessment did not provide for the inclusion of dental care in her/his care plan. On 4/6/23 at 9:13 AM Staff 15 (CNA) reported she assisted Resident 2 with oral…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-08-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 52.5+2.5 vs chain
Health inspection 4 of 52.4+1.6 vs chain
Staffing 5 of 53.3+1.7 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 43 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Alaska Gardens Health and RehabilitationTacoma, WA 1 of 5El Jen Skilled CareLas Vegas, NV 1 of 5Firesteel Healthcare CenterMitchell, SD 1 of 5Gardnerville Health & Rehabilitation CenterGardnerville, NV 1 of 5Laurel Health & Rehabilitation CenterLaurel, MT 1 of 5Livingston Health & Rehabilitation CenterLivingston, MT 1 of 5Palisade Healthcare CenterGarretson, SD 1 of 5Portland Health And RehabilitationPortland, OR 1 of 5Riverview Healthcare CenterFlandreau, SD 1 of 5Shepherd of the Valley Rehabilitation and WellnessCasper, WY 1 of 5Worland Health and RehabilitationWorland, WY 2 of 5Aspen Meadows Health And Rehabilitation CenterBillings, MT 2 of 5Canterbury HouseAuburn, WA 2 of 5Enumclaw Health and RehabilitationEnumclaw, WA 2 of 5Granite Rehabilitation and WellnessCheyenne, WY 2 of 5Independence Health And RehabilitationIndependence, OR 2 of 5Laramie Health and RehabilitationLaramie, WY 2 of 5Mountain View Health And RehabilitationCarson City, NV 2 of 5North Cascades Health and RehabilitationBellingham, WA 2 of 5Seattle Medical Post Acute CareSeattle, WA 2 of 5Shelton Health and RehabilitationShelton, WA 2 of 5Village Health CareGresham, OR 2 of 5Wind River Rehabilitation and WellnessRiverton, WY 3 of 5Fountain Springs HealthcareRapid City, SD 3 of 5La Grande Post Acute RehabLa Grande, OR 3 of 5Pahrump Health And RehabilitationPahrump, NV 3 of 5Prairie View Healthcare CenterWoonsocket, SD 3 of 5Rawlins Rehabilitation and WellnessRawlins, WY 3 of 5Royal Park Health and RehabilitationSpokane, WA 3 of 5Sage View Care CenterRock Springs, WY 3 of 5Thermopolis Rehabilitation and WellnessThermopolis, WY 3 of 5Wheatcrest Hills Healthcare CenterBritton, SD 3 of 5Windsor Health And RehabilitationSalem, OR 4 of 5Americana Health and RehabilitationLongview, WA 4 of 5Buena Vista HealthcareColville, WA 4 of 5Frontier Rehabilitation and Extended CareLongview, WA 4 of 5Hillsboro Health And RehabilitationHillsboro, OR 4 of 5Hot Springs Health & Rehabilitation CenterHot Springs, MT 4 of 5Missoula Health & Rehabilitation CenterMissoula, MT 4 of 5Polson Health & Rehabilitation CenterPolson, MT

Showing 40 of 43; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
MILTON FREEWATER SNF OPERATIONS, LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 08/31/2023
PACIFIC NORTHWEST 12 LEASED OPERATIONS HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 08/31/2023
CH PNW 12 HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 08/31/2023
COUVE FINANCIAL SERVICES LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/02/2025
COUVE HEALTHCARE CONSULTING LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/02/2025
FREEWATER OREGON LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 06/02/2025
PNW 12 OPCO MANAGEMENT LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/02/2025
PNW 12 SNF CONSULTING LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/02/2025
WITZCORP PNW 12 LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 08/31/2023
ASHBY, WILLIAMIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
CHAMBERS, RANDYIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
HERZKA, YISROELIndividualINDIRECT OWNERSHIP INTERESTsince 08/31/2023
HYDE, DEIDREIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
ODENTHAL, JASONIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
SPIELMAN, SHIMONIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023
YENOWITZ, YITZCHOKIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/31/2023

CMS files one row per role, so the 39 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.3M
Net patient revenuemost recent cost report
-13.7%
Operating marginrevenue minus expenses
$100K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 16%Other / private 20%

This home reported $100K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$609per resident / day
operating cost
$18,516per month
≈ monthly operating cost
$536per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OR

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oregon Medicaid page.

Typical monthly cost in Oregon
$16,760/mo
Nursing home (semi-private)
$18,448/mo
Nursing home (private)
$6,875/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385161. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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