Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- OregonAbove 78% of peers127 rated homes · average 3.1★
- United StatesAbove 80% of peers14,605 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point4★+1.2 vs OR avg
- StaffingCan add or remove a star5★+1.1 vs OR avg
- Quality measuresCan add or remove a star2★−1.5 vs OR avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles4★Above 65% of peersOR avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 75% of peersOR avg3.9★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 1% of peersOR avg3.5★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff5.34hrsAbove 82% of peersOR avg5.03Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only1.16hrsTop 8%OR avg0.72Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better34%Above 85% of peersOR avg47%RN turnover46%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$8,278Above only 46% of peersOR avg$28,745Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2023 – Jan 2026
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jan 15, 2026Cycle 1worst D · no actual harm
- F0602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 26, 2025
- F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 6, 2025
- F0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Feb 10, 2026
- F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Feb 10, 2026
- F0757Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Feb 10, 2026
Aug 7, 2025Cycle 1worst G · actual harm$8,278
- F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 28, 2025
- F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 28, 2025
- F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 28, 2025
- F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 28, 2025
Jun 28, 2024Cycle 2worst E · no actual harm
- F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Aug 12, 2024
- F0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Aug 12, 2024
- F0641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Aug 12, 2024
- F0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Aug 12, 2024
- F0685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Aug 12, 2024
- F0688Provide 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.Quality of Life and CareD · isolatedCorrected Aug 12, 2024
- F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Aug 12, 2024
- F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 12, 2024
Apr 7, 2023Cycle 3worst E · no actual harm
- F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected May 22, 2023
- F0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected May 22, 2023
- F0602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 3, 2023
- F0641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 22, 2023
- F0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected May 22, 2023
- F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 22, 2023
- F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 3, 2023
- F0757Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected May 22, 2023
- F0791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected May 22, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined5.34hrs
- Registered nursesRN hours only1.16hrs
- Licensed practical nursesLPN hours0.14hrs
- Nurse aidesCNA hours4.04hrs
- Weekend nursingAll staff on Saturdays and Sundays4.69hrs
- Oregon average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better34%Above 85% of peersOR avg 47%
- RN turnoverRegistered nurses only46%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy70 certified beds · ~32 residents a day45%Above only 9% of peersOR avg 72%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $8,278In fines
- 1Fine
- 0Payment denials
- $28,745OR avg in fines
Actions on record
- Aug 7, 2025Civil money penalty$8,278
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Evergreen Healthcare Group44 facilities in the chain2.5★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- Couve Healthcare Consulting LLC
- Freewater Oregon LLC
- Pnw 12 Opco Management LLC
- Pnw 12 SNF Consulting LLC
- Couve Financial Services LLC
- William Ashby
- Randy Chambers
- Deidre Hyde
- +3 more
- Freewater Oregon LLC
- Pnw 12 Opco Management LLC
- Pnw 12 SNF Consulting LLC
- Witzcorp Pnw 12 LLC
- William Ashby
- Randy Chambers
- Yisroel Herzka
- Deidre Hyde
- +6 more
- Jason Odenthal
- Couve Financial Services LLC
- Couve Healthcare Consulting LLC
- Milton Freewater SNF Operations, LLC
- Pnw 12 Opco Management LLC
- Pnw 12 SNF Consulting LLC
- William Ashby
- Randy Chambers
- Deidre Hyde
- +3 more
- Milton Freewater SNF Operations, LLC
- Pacific Northwest 12 Leased Operations Holdings LLC
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed August 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 385161 · 120 ELZORA STREET, MILTON FREEWATER, OR, 97862.
- Percentiles compare this facility with every rated nursing home in Oregon and Umatilla County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
