Cycle 1
Health 2026-01-15 · Fire 2026-01-15
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Milton Freewater, OR
Milton Freewater Health & Rehabilitation Center
3-star overall rating with 2-star inspections with abuse icon flag with $8,278 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
120 Elzora Street, Milton Freewater, OR
(541) 938-3318
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
31
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1984-01-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.24
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
4.09
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.74
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
5.83
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,759
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.43
Baseline 16.78% · Performance 20.77% · Measure score 1.43 · Achievement 1.43 · Improvement 0
Healthcare-associated infections
0
Baseline 5.26% · Performance 8.54% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.79
Baseline 64.86% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 5.71
Adjusted total nurse staffing
4.33
Baseline 3.84 hours · Performance 4.31 hours · Measure score 4.33 · Achievement 4.33 · Improvement 1.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 12.12% · Lower 95% interval 7.13% |
| Discharge to community | 30.09% |
50.57%
20.5 pts worse
|
Worse than the National Rate · Eligible stays 67 · Observed rate 20.9% · Lower 95% interval 22.44% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 33 · Denominator 34 |
| Falls with major injury | 5.88% |
0.77%
5.1 pts worse
|
Numerator 2 · Denominator 34 |
| Discharge self-care score | 46.15% |
53.69%
7.5 pts worse
|
Numerator 12 · Denominator 26 |
| Discharge mobility score | 38.46% |
50.94%
12.5 pts worse
|
Numerator 10 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.54% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 14.29% · Lower 95% interval 4.6% |
| Staff COVID-19 vaccination coverage | 3.23% |
8.2%
5 pts worse
|
Numerator 2 · Denominator 62 |
| Staff flu vaccination coverage | 63.51% |
42%
21.5 pts better
|
Numerator 47 · Denominator 74 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 13 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.76% |
25.2%
20.4 pts worse
|
Numerator 1 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.4
1.6 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.5
0.5 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
95.5%
3.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.2% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.3% |
95.2%
3.9 pts worse
|
95.5%
4.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
2.4%
1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 4.8% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.7%
2.1 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
12.5%
About the same
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 15.0% · Q3 9.5% · Q4 12.0% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
14.7%
4.4 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 14.3% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
15.8%
3.3 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q4 21.7% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
22.2%
3.2 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 16.8% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
6.5%
4.4 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q4 3.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
85.4%
1.9 pts better
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.2% · Q2 78.1% · Q3 91.9% · Q4 95.1% · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
15.1%
1 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 16.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.6% |
81.2%
20.6 pts worse
|
79.7%
19.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
21.6%
2 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 26.2% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-28 · Fire 2024-06-28
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-04-07 · Fire 2023-04-07
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-10
F · Potential for more than minimal harm
2024-06-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-12
F · Potential for more than minimal harm
2023-04-07
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-04-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-04-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-04-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-04-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-04-07
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-05-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-11-26
D · Potential for more than minimal harm
2026-01-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-06
D · Potential for more than minimal harm
2026-01-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-10
G · Actual harm
2025-08-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-08-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-08-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-08-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-28
E · Potential for more than minimal harm
2024-06-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-12
E · Potential for more than minimal harm
2023-04-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-07
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-07
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-04-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-04-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-07
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-05-22
Penalties and ownership
What sits behind the stars
$8,278
2025-08-07
Fine
Fine · fine $8,278
Fine
Ownership
Ashby, William
Operational/Managerial Control · Individual
Chambers, Randy
Operational/Managerial Control · Individual
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Hyde, Deidre
Operational/Managerial Control · Individual
Milton Freewater SNF Operations, LLC
Operational/Managerial Control · Organization
Odenthal, Jason
Operational/Managerial Control · Individual
Pnw 12 Opco Management LLC
Operational/Managerial Control · Organization
Pnw 12 SNF Consulting LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
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