Milton Freewater Health and Rehabilitation
120 Elzora Street · Milton Freewater, OR · 97862 · 5419383318
70 certified beds For profit - Corporation Chain: Evergreen Healthcare Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection results are getting worse cycle over cycle, not better.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 5 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 5.90 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.20 | 0.55–0.75 |
| Weekend hours / resident-day | 5.34 | ≈ weekday level |
| Nursing turnover / year | 28% | median 45% |
| Fines (3-yr window) | 1 · $8,278 |
Inspection citations (26 in the current record)
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Potential for harm · D January 15, 2026
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 February 10, 2026 · Quality of Life and Care
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Potential for harm · D January 15, 2026
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected February 10, 2026 · Nursing and Physician Services
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Potential for harm · D January 15, 2026
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected February 10, 2026 · Pharmacy Service
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Potential for harm · D January 15, 2026 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected November 26, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 15, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 6, 2025 · Quality of Life and Care
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Actual harm · G August 7, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 28, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 7, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 7, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 28, 2025 · Quality of Life and Care
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Potential for harm · D June 28, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 12, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 28, 2024
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected August 12, 2024 · Resident Rights
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Potential for harm · D June 28, 2024
Ensure each resident receives an accurate assessment.
Corrected August 12, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 28, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected August 12, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 28, 2024
Assist a resident in gaining access to vision and hearing services.
Corrected August 12, 2024 · Quality of Life and Care
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Potential for harm · D June 28, 2024
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 August 12, 2024 · Quality of Life and Care
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Potential for harm · D June 28, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected August 12, 2024 · Resident Assessment and Care Planning
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Potential for harm · E June 28, 2024 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected August 12, 2024 · Nursing and Physician Services
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Potential for harm · D April 7, 2023
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected May 22, 2023 · Resident Rights
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Potential for harm · D April 7, 2023
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected March 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 7, 2023
Ensure each resident receives an accurate assessment.
Corrected May 22, 2023 · Resident Assessment and Care Planning
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Potential for harm · D April 7, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected May 22, 2023 · Resident Assessment and Care Planning
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Potential for harm · D April 7, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 22, 2023 · Quality of Life and Care
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Potential for harm · D April 7, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 3, 2023 · Pharmacy Service
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Potential for harm · D April 7, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 22, 2023 · Pharmacy Service
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Potential for harm · D April 7, 2023
Provide or obtain dental services for each resident.
Corrected May 22, 2023 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 7, 2025 | Fine | $8,278 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385161 · certified since January 20, 1984. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.