Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Milton Freewater Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with a suprapubic catheter and recent UTIs had catheter tubing repeatedly observed on the floor while in a recliner, wheelchair, hallway, and room. Staff, including a CNA, RN, DNS, and IP, acknowledged the tubing should never be on the floor and that the resident required frequent checking of catheter placement, but the tubing was still found unsecured during multiple observations.
Insufficient staffing resulted in missed bathing care for multiple residents. Residents with colon cancer, lymphedema, and post-stroke paralysis/weakness had care plans for scheduled showers or bed baths, but task logs showed repeated missed bathing activities. CNAs and RNs stated showers were the main care task affected when the facility was short-staffed, and the DON acknowledged the residents did not receive bathing as scheduled.
Unnecessary Antibiotic Use for Resident With Cough: A cognitively intact resident with CHF was given Mucinex for a nonproductive cough while remaining afebrile and not short of breath. Staff later reported mixed symptoms to the MD, and doxycycline was ordered for 5 days even though the chart did not show asthma or COPD and staff stated the resident’s only clear indication was a cough and that no clinical tool was used to support the antibiotic decision.
Misappropriation of PRN Pain Medication: A facility failed to prevent diversion of hydrocodone-acetaminophen for two residents reviewed for misappropriation. One resident with a below-the-knee amputation and another resident with hemiplegia both had MAR entries showing nighttime or early-morning doses that did not match their usual pain-medication routines or their statements that they had not requested the medication. Staff later found a pattern of inconsistent narcotic documentation across multiple residents, including residents who were mostly non-verbal and did not typically request PRN pain meds.
Failure to follow a physician order for seizure medication led to missed levetiracetam doses for a resident with convulsions. The MAR showed the med was discontinued in error instead of being held for a lab draw, and the resident had mild seizure activity while the doses were missed.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The report highlights insufficient environmental safety measures and inadequate supervision protocols.
A resident with a history of aggressive behavior physically assaulted another resident by throwing a beverage bottle, resulting in a facial injury. The incident occurred while staff were occupied elsewhere, and prior care plan interventions for the aggressive resident were not effectively implemented, leading to harm.
A resident with severe cognitive impairment and total dependence for transfers developed significant swelling and bruising on the chest and abdomen after a transfer incident. Although a nurse notified facility leadership about the injury, no Facility Reported Incident (FRI) was submitted to the State Survey Agency as required, and the injury was not reported within mandated timelines.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a failure to meet the resident's individualized care plan.
The facility experienced significant staffing shortages, particularly during evening and night shifts, resulting in unmet resident needs and delayed care. Many residents required extensive assistance, and observations showed long periods without CNA presence. Residents reported long wait times for call light responses and pain medication, while staff confirmed the impact of low staffing on care quality. The DNS and Administrator acknowledged the issue, noting inadequate CNA coverage across multiple shifts.
Two residents with aggressive behaviors engaged in physical altercations due to ineffective intervention by the facility. Despite care plans addressing their aggression, incidents occurred where one resident disturbed another's belongings, leading to physical abuse. Staff witnessed these events, confirming the need for immediate intervention.
A resident with major depression and repeated falls was not involved in their care planning process, as no care conference was held since late last year. Despite updates to the care plan, the resident expressed dissatisfaction with the lack of involvement. Staff cited difficulties in organizing care conferences due to staffing changes, acknowledging the resident's absence from the process.
A facility failed to accurately assess a resident for falls. The resident, admitted with dementia, had a discrepancy in their fall history. The March 2024 Quarterly MDS indicated a fall with major injury, but the DNS later confirmed no falls had occurred since the previous assessment, revealing an inaccuracy in the MDS documentation.
The facility failed to provide baseline care plans to three residents within 48 hours of admission, as required. A resident with dementia, another with a compression fracture, and a third with depression did not receive written summaries of their care plans. Staff interviews revealed a lack of awareness and a systemic issue in ensuring care plans were communicated to residents.
A resident with major depression and repeated falls was not assisted in accessing vision care services, despite a physician's order for an eye examination due to visual changes. The resident's health record lacked evidence of any discussion, scheduling, or completion of the examination. Observations showed the resident was not wearing glasses, and the resident reported requesting them months ago without follow-up. The DNS confirmed the absence of documentation regarding the eye examination.
A resident with age-related debility was not walked by staff as required by their Walk Daily Program after being discharged from PT services. Despite the program's inclusion in the resident's care plan, observations and staff interviews confirmed the resident was not walked, with staff citing workload as a barrier. The resident expressed concern about losing mobility due to this inaction.
Two residents in the facility did not have their medication administration documented on two occasions, despite the medications reportedly being given. A nurse, distracted during shift changes, failed to record the administration of levothyroxine for a resident with hypothyroidism and Protonix for a resident with a stomach ulcer, as confirmed by the DNS.
Catheter Tubing Left on Floor
Penalty
Summary
The facility failed to ensure appropriate catheter care for one resident with an indwelling suprapubic catheter when staff did not keep the catheter tubing off the floor. Resident 13 was admitted with diagnoses including presence of urogenital implants and obstructive and reflux uropathy, and the quarterly MDS indicated the resident was moderately cognitively impaired and had an indwelling catheter and a UTI in the past 30 days. The care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance to the room, and to check for a catheter strap or securement device. During multiple observations, Resident 13’s catheter tubing was seen on the floor while the resident was in a recliner, wheelchair, hallway, and room, including tubing filled with clear yellow urine. Staff did not secure the tubing during several of these observations, including when a CNA was nearby and when the DNS entered the room and acknowledged the tubing was on the floor. The resident’s infection report showed a UTI with an indwelling catheter, and multiple staff members stated the tubing should never be on the floor and that the resident had experienced recent UTIs and needed frequent checking and fixing of the tubing.
Insufficient staffing led to missed resident bathing care
Penalty
Summary
The facility failed to provide sufficient staffing to meet resident care needs, and the deficiency was identified for 3 residents reviewed for sufficient and competent staffing. The report states that residents were not receiving scheduled showers or bed baths because staff were short-staffed, and multiple CNAs and RNs described that resident showers were the area of care most affected when staffing was inadequate. Staff also stated that when a bathing task could not be completed, the resident often had to wait until the next scheduled bathing day. One resident, admitted with colon cancer and documented as cognitively intact, had a care plan directing that a shower be offered each day on dayshift with assistance from 2 staff. The bathing task log showed multiple missed bathing opportunities over the review period, including several dates when bathing activity did not occur. The resident stated a bed bath scheduled for the prior day was not offered and that bathing occurred only about once a week, although more frequent bathing was preferred. Staff confirmed that showers were not completed when the facility was short-staffed and that bathing tasks were sometimes marked as not occurring because there was not enough time. A second resident, admitted with lymphedema and documented as cognitively intact, had a care plan indicating a preference for a shower or bed bath and scheduled bathing on Tuesdays and Fridays. The bathing task log showed missed bathing activities on multiple dates, including the day of observation. The resident stated the facility was short-handed and that scheduled showers or bed baths were not always received or offered. A third resident, admitted after a stroke with hemiplegia and hemiparesis and dependent on staff for all bathing, was to receive a bed bath or shower twice weekly. The bathing task log showed a missed bathing activity, and the resident stated a scheduled bed bath was not offered and would have to wait until the next scheduled day. The Director of Nursing acknowledged that the residents did not receive showers as scheduled and stated she expected showers to be completed even when the facility was short-staffed.
Unnecessary Antibiotic Use for Resident With Cough
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary antibiotic use. The resident was admitted with congestive heart failure and was cognitively intact on the admission MDS. After the resident complained of a nonproductive cough, the record showed the resident received Mucinex daily for cough congestion while remaining afebrile, not short of breath, and not observed to cough. A progress note later documented that the Medical Director was notified the resident reported coughing since early December, said the cough medicine was ineffective, reported brown sputum, and had wheezing, but vital signs were stable and there was no fever. The resident requested antibiotics, and the MAR showed doxycycline was ordered twice daily for 5 days. Staff statements were inconsistent about the resident’s symptoms at the time the antibiotic was prescribed: one RN recalled a dry, nonproductive cough with stable vital signs, another RN stated the resident had a cough and requested an antibiotic, and the Medical Director stated he prescribed doxycycline based on reports of shortness of breath, sputum production, and fever, though he also said he would have prescribed it for a resident with asthma or COPD even without those symptoms. The record contained no evidence that the resident had asthma or COPD. The RN who documented the report stated she did not use any clinical tool to gather and report symptoms to the Medical Director, and the IP later stated a cough alone was not a sufficient indication for doxycycline. The IP also stated an x-ray should have been ordered and staff should have challenged the antibiotic order, while the RNCM stated the only indication for the antibiotic was a cough.
Misappropriation of PRN Pain Medication
Penalty
Summary
The facility failed to prevent the wrongful use of residents’ medications when a pattern of hydrocodone-acetaminophen administration records did not match resident reports and usual routines for two residents reviewed for misappropriation. Resident 38 was admitted with a below-the-knee amputation from frostbite and had a physician order for hydrocodone-acetaminophen as needed for pain. The resident’s MAR showed four doses documented on one day, including doses during the night and early morning, but the resident stated pain was usually managed with one dose in the morning and one in the evening and that extra doses were not requested. Staff later identified that the resident had not requested or received additional hydrocodone outside the normal routine on that date. Resident 29 was admitted with hemiplegia and had a physician order for hydrocodone-acetaminophen every four hours as needed for pain. The MAR documented a dose given in the middle of the night by an RN, but the resident reported sleeping through the night and stated the medication had not been received at that time. The resident also reported requesting pain medication in the morning and being told it was too early because a dose had already been given earlier. Staff noted the resident’s account was unusual and inconsistent with the documented administration time. After concerns were raised, staff reviewed medication records for multiple residents and found a pattern of documented hydrocodone-acetaminophen administration during the night to residents who had not requested the medication, including several residents who were mostly non-verbal and did not have a history of requesting PRN pain medication. Facility leadership later confirmed that misappropriation of residents’ pain medications had occurred by a staff member on at least three administrations, and that the pattern involved multiple residents whose records conflicted with their reported routines and statements.
Failure to Follow Seizure Medication Orders
Penalty
Summary
The facility failed to follow physician orders for a resident with diagnoses including pneumonia and unspecified convulsions. The resident’s MAR showed levetiracetam was ordered twice daily for seizure management, and a laboratory order was also present for a levetiracetam level to be drawn before the morning dose. However, the resident did not receive levetiracetam on three consecutive days, and medication administration resumed afterward. The resident’s record also showed the resident was cognitively intact on the annual MDS. The facility investigation found that the resident’s levetiracetam administration order had been discontinued in the electronic record instead of being placed on hold for the ordered blood draw. The resident was reported to have had mild seizure activity during the period when the medication was not administered. In later interviews, the resident recalled having seizures and stated the whole body shook for several minutes, while staff reported the resident was assessed and found to have no adverse effects from the seizure. Staff identified that the medication had been discontinued rather than held for the lab draw, and the resident’s seizure medication order was then reinstated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific hazards, the nature of the supervision lapse, or information about the residents involved were provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident physically assaulted another. Resident 10, who had a history of stroke, dysphagia, and documented behavioral issues including verbal and physical aggression, threw a beverage bottle at Resident 11, striking them in the face and causing a small cut on the bridge of the nose. At the time of the incident, all staff were reported to be in resident rooms providing care to other residents, leaving the area unsupervised. Resident 10's care plan included interventions such as providing distractions and monitoring the resident at all times during meals due to their aggressive behaviors, but these interventions were not effectively implemented at the time of the incident. Resident 11, who had no cognitive impairment or behavioral issues, was injured as a result of the altercation. Staff interviews confirmed that Resident 10 had a pattern of aggressive behavior, including previous altercations with Resident 11 and other residents, as well as incidents of physical aggression toward staff. Documentation showed that Resident 10 had initiated several incidents with other residents and staff in the months leading up to the event, but no physical harm had been documented until this incident. The facility's failure to adequately supervise and implement care plan interventions for Resident 10 resulted in harm to Resident 11.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the appropriate State agency within the required state-mandated timelines for one resident. The resident, who had severe cognitive impairment, was completely dependent for transfers and required a two-person assist with a Hoyer sling. The resident was admitted with diagnoses including acute post-hemorrhagic anemia and dysphagia. On a specific date, a nurse observed that the resident's left breast was swollen to three times the size of the right, was engorged, hard to palpate, and had a firm lump, along with bruising on the left side of the abdomen. The nurse was informed that the resident had screamed during a transfer with a sit-to-stand device, and the incident was reported to the evening shift nurse. The nurse who discovered the injury communicated the findings to the facility's administrator and director of nursing, believing the injury should be reported. Despite this, no Facility Reported Incident (FRI) was submitted to the State Survey Agency regarding the injury. Public complaints were later received by the State Survey Agency, indicating that the resident had significant bruising and swelling and was not sent to the hospital for several days after the injuries became apparent. Upon review, facility leadership confirmed that the injury of unknown origin was not reported as required.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as observed and reported during a survey. The facility had a census of 26 residents, with many requiring extensive assistance for daily activities such as transfers, bathing, toileting, and dressing. Observations revealed that there were times when no CNA staff were present in the hallways for up to 30 minutes. Residents reported long wait times for call light responses, with some waiting up to 30 minutes for assistance with incontinence care and others waiting over an hour for pain medication. Staff interviews confirmed that staffing shortages were a persistent issue, particularly during evening and night shifts, leading to unmet care needs and delayed medication administration. Residents and staff expressed concerns about the impact of staffing shortages on care quality. One resident reported crying due to long wait times for assistance, while another resident stopped using the call light due to delays. Staff members indicated that high-acuity residents, including those with dementia and behavioral health needs, were not adequately monitored, leading to increased falls and resident distress. The facility's DNS and Administrator acknowledged the staffing issues, noting that multiple shifts lacked adequate CNA coverage, which was mentally draining for staff and resulted in incomplete resident care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving two residents with aggressive behaviors. Resident 7, diagnosed with dementia and behavioral disturbances, and Resident 17, with hemiplegia and normal cognitive function, both exhibited physical and verbal aggression. Their care plans included interventions to manage these behaviors, but these were not effectively implemented. On two separate occasions, Resident 7 disturbed Resident 17's personal items, leading to physical altercations where both residents struck each other. Staff members witnessed these incidents, confirming the physical abuse between the residents. The first incident occurred when Resident 7 disturbed Resident 17's belongings, resulting in Resident 17 punching Resident 7. The second incident involved Resident 17 yelling at and attempting to strike Resident 7 after finding them near their personal items. Staff members, including a Registered Nurse and a Housekeeping Manager, witnessed these altercations and confirmed the need for immediate intervention to separate the residents. Despite the care plans in place, the facility's failure to effectively intervene and prevent these incidents resulted in a deficiency in protecting residents from abuse.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to ensure that residents were given the right to participate in the development of their person-centered care plan, as evidenced by the case of a resident admitted in April 2023 with diagnoses including major depression and repeated falls. The resident's health record showed that no care conference had been completed since November 9, 2023, despite updates to the care plan on several occasions in 2024. The resident expressed dissatisfaction with not being involved in the care planning process, noting that other residents participated regularly in care conferences. Staff confirmed that due to changes in staff, it was difficult to organize care conferences, and acknowledged that the resident had not had a care conference since November 2023, although they were expected to be offered at least quarterly.
Inaccurate Fall Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess a resident for falls, which was identified during an interview and record review. The resident, who was admitted in October 2023 with a diagnosis of dementia, had a discrepancy in their fall history. The Quarterly MDS dated March 28, 2024, indicated that the resident had experienced one fall with a major injury since the previous MDS assessment on January 3, 2024. However, on June 24, 2024, the Director of Nursing Services (DNS) stated that the resident had not experienced any falls since the prior assessment, indicating that the fall section of the March 28, 2024, Quarterly MDS was inaccurate.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to develop and provide a summary of the baseline care plan for three residents within 48 hours of their admission, as required. Resident 25, admitted with dementia, did not receive a written summary of the baseline care plan, and the Director of Nursing Services (DNS) was unaware if it had been provided. Similarly, Resident 180, admitted with a compression fracture, did not have a baseline care plan developed within the required timeframe, and there was no evidence of resident-centered pain interventions being included or communicated to the resident. Resident 26, admitted with depression, also did not receive a written summary of the baseline care plan. The Divisional Director of Clinical Operations confirmed the absence of documentation indicating that the baseline care plan was discussed or offered to the resident. Furthermore, it was acknowledged that there was no system in place to ensure that baseline care plans were provided to residents and their representatives, highlighting a systemic issue in the facility's admission process.
Failure to Assist Resident with Vision Care Needs
Penalty
Summary
The facility failed to assist a resident in accessing necessary vision care services, which placed the resident at risk for impaired vision. The resident, admitted in April 2023 with diagnoses including major depression and repeated falls, was referred for an eye examination in December 2023 due to visual changes and double vision. However, a review of the resident's health record showed no evidence that an eye examination was discussed, scheduled, or completed. Observations over several days in June 2024 revealed that the resident was not wearing glasses, and the resident reported having requested glasses several months prior without any follow-up. The Director of Nursing Services confirmed the lack of documentation regarding the eye examination in the resident's health record.
Failure to Maintain Resident Mobility Post-PT Discharge
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in mobility for a resident who was reviewed for rehabilitation services. The resident was admitted to the facility with age-related debility and was discharged from physical therapy (PT) services. Despite having a Walk Daily Program task that required the resident to be walked by CNA staff from their room to the nursing station and back every day before lunch, there was no evidence that this was carried out after the resident's discharge from PT services. Observations over several days revealed that the resident was not walked by staff, and interviews with the resident and staff confirmed this lack of action. The resident expressed concern about not walking for at least two weeks, emphasizing the importance of maintaining mobility to avoid becoming weak. Staff members, including a physical therapy assistant and CNAs, acknowledged that the resident was supposed to be walked daily but admitted that this was not happening. One CNA mentioned the inability to walk the resident due to the high number of residents assigned to her, and the Director of Nursing Services confirmed that the Walk Daily Program was not being completed.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, leading to a risk of inaccurate treatment. Resident 6, diagnosed with hypothyroidism, was prescribed levothyroxine to be administered daily before breakfast. However, the Medication Administration Record (MAR) for May 2024 showed no documentation of the medication being given on two specific days. The Director of Nursing Services (DNS) confirmed that the nurse responsible was distracted during shift changes and did not document the administration, although the medication was reportedly given. Similarly, Resident 10, with a diagnosis of a stomach ulcer, was prescribed Protonix to be taken daily before meals. The MAR for May 2024 also lacked documentation for the same two days as Resident 6. The DNS stated that the same nurse was involved and failed to document the administration due to distractions during shift changes, despite the medication being administered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Milton Freewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At The Park | 7.4 mi | ★★★★★ | 13 | 0 |
| Park Manor Rehabilitation Ctr | 7.8 mi | ★★★★★ | 12 | 0 |
| Washington State Walla Walla Veterans Home | 8.4 mi | ★★★★★ | 28 | 0 |
| Washington Odd Fellows Home | 9.6 mi | ★★★★★ | 1 | 0 |
| Willowbrook Post Acute | 28.5 mi | ★★★★★ | 18 | 0 |
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