Report
TheVardellReport
Milton Freewater Health and Rehabilitation
Skilled nursing facility and nursing facility
120 Elzora Street
Milton Freewater, OR 97862
Report
← Milton Freewater Health and Rehabilitation, free profile
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The Vardell Report.Milton Freewater Health and Rehabilitation
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Milton Freewater, OR
- Record Period
- 2023–2026
- Source Documents
- 6
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 4 inspections from April 2023 to January 2026, state surveyors documented 26 findings at Milton Freewater Health and Rehabilitation; 26 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 4
- 2023–2026, standard and complaint
- Findings
- 26
- Deficiencies cited by state inspectors
- Corrected
- 26
- Of 26 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 9 | 0 |
| 2024 | 1 | 8 | 0 |
| 2025 | 1 | 4 | 1 |
| 2026 | 1 | 5 | 0 |
What the Record Shows
- 26 of 26 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $8,278, its payment not published.
- 3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, January 15, 2026, recorded 5 findings (most serious: Level D).
What to Ask About
- Quality of Care, Cited in Three Inspections
- Citation F553, Cited in Two Inspections
- Protection From Abuse and Neglect, Cited in Two Inspections
- Citation F602, Cited in Two Inspections
- Accurate Assessments, Cited in Two Inspections
- The First 48 Hours, Cited in Two Inspections
- Nursing Staff Levels, Cited in Two Inspections
- Citation F757, Cited in Two Inspections
- Medical Records, Cited in Two Inspections
Report at a Glance
- Facility
- Milton Freewater Health and Rehabilitation
- Address
- 120 Elzora Street, Milton Freewater, OR 97862
- CMS Certification Number
- 385161
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 70
- Ownership
- For profit - Corporation
- Record Window
- April 7, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
5 findings
The same visit included a complaint investigation.
- F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Nov 26, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 6, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Feb 10, 2026
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Feb 10, 2026
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Feb 10, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
4 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Aug 28, 2025
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 28, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 28, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 28, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
8 findings
The same visit included a complaint investigation.
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Aug 12, 2024
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Aug 12, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 12, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Aug 12, 2024
- F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Aug 12, 2024
- F688Provide 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.Level DNo actual harm, potential for moreCorrected Aug 12, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Aug 12, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 12, 2024
Enforcement Action
Civil money penalty, $8,278 imposed August 7, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 28, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
9 findings
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected May 22, 2023
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected May 22, 2023
- F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Mar 3, 2023
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 22, 2023
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected May 22, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 22, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 3, 2023
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected May 22, 2023
- F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected May 22, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in April 2023, August 2025 and January 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F684 across all 4 inspections, oldest to newest - 2
Citation F553, Cited in Two Inspections
Inspectors cited F553 in April 2023 and June 2024. The agency describes it this way: Allow resident to participate in the development and implementation of his or her person-centered plan of care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F553 across all 4 inspections, oldest to newest - 3
Protection From Abuse and Neglect, Cited in Two Inspections
Inspectors cited F600 in June 2024 and August 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F600 across all 4 inspections, oldest to newest - 4
Citation F602, Cited in Two Inspections
Inspectors cited F602 in April 2023 and January 2026. The agency describes it this way: Protect each resident from the wrongful use of the resident's belongings or money. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F602 across all 4 inspections, oldest to newest - 5
Accurate Assessments, Cited in Two Inspections
Inspectors cited F641 in April 2023 and June 2024. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F641 across all 4 inspections, oldest to newest - 6
The First 48 Hours, Cited in Two Inspections
Inspectors cited F655 in April 2023 and June 2024. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F655 across all 4 inspections, oldest to newest - 7
Nursing Staff Levels, Cited in Two Inspections
Inspectors cited F725 in June 2024 and January 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F725 across all 4 inspections, oldest to newest - 8
Citation F757, Cited in Two Inspections
Inspectors cited F757 in April 2023 and January 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F757 across all 4 inspections, oldest to newest - 9
Medical Records, Cited in Two Inspections
Inspectors cited F842 in April 2023 and June 2024. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242526F842 across all 4 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level D.
- 02
What changed after F553 was cited, and how do you check it now?
Citation F553: cited in two inspections, most seriously at level D.
- 03
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.
- 04
What changed after F602 was cited, and how do you check it now?
Citation F602: cited in two inspections, most seriously at level D.
- 05
Who completes resident assessments, and how are they checked for accuracy?
Accurate Assessments: cited in two inspections, most seriously at level D.
- 06
What happens in the first 48 hours after admission, and who writes the first care plan?
The First 48 Hours: cited in two inspections, most seriously at level D.
- 07
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Nursing Staff Levels: cited in two inspections, most seriously at level E.
- 08
What changed after F757 was cited, and how do you check it now?
Citation F757: cited in two inspections, most seriously at level D.
- 09
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level E.
- 10
What led to the 2025 fine, and has it been paid?
An $8,278 civil money penalty was imposed August 7, 2025. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oregon state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Apr 7, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Jun 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Aug 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Jan 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 385161
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowApril 7, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before April 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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