Milton Freewater Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Milton Freewater Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 7, 2025

  Based on interview and record review, it was determined the facility failed to follow care planned interventions related to transfers for 1 of 3 sampled residents (#13) reviewed for safety. As a result, Resident 13 experienced an injury of unknown origin and internal bleeding, which required hospitalization and a blood transfusion. Findings include: Resident 13 was admitted to the facility in 4/2025 with diagnoses including acute post-hemorrhagic anemia (a condition where a person experiences a rapid decrease in red blood cells and hemoglobin due to significant blood loss) and dysphagia (difficulty swallowing). Resident 13's MDS Quarterly dated 7/7/25 revealed a BIMS score of 4, indicating severe cognitive impairment. […]

• Actual harm, isolatedF689Jul 14, 2022

  Based on interview and record review it was determined the facility failed to ensure care planned interventions were followed for 1 of 3 sampled residents (#1) reviewed for falls and failed to prevent elopement for 1 of 1 sampled resident (#4) reviewed for elopement. As a result of facility staff not following the care planned interventions, Resident 1 fell and sustained a [CONDITION(S)]. Findings include: 1. Resident 1 admitted to the facility in 2013 with diagnoses including hypertension and depression. Resident 1's care plan in 2/2022 directed staff to provide two person extensive assist to turn, reposition and to provide care with bed mobility. […]

• No harm, potential for more than minimal, widespreadF885Feb 8, 2022

  Based on interview and record review it was determined the facility failed to inform residents, resident representatives and families by five PM the next calendar day following the occurrence of a suspected or confirmed COVID-19 infection. This placed residents at risk for not being informed of the facility's COVID-19 outbreak status. Findings include: On 2/7/22 at 2:45 PM Staff 1 (Executive Director) provided a COVID-19 infection notification letter, dated 11/15/21. The letter included notification of a positive case of COVID-19 and mitigating actions taken by staff. On 2/7/22 at 2:49 PM Staff 1 stated after the occurrence of a suspected or confirmed COVID-19 infection, she drafted a notification letter. […]

• No harm, potential for more than minimal, patternF725Jun 28, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 6/23/24 the facility had a census of 26 residents. On 6/27/24, Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 13; -Required one or two-person extensive or total assistance for bathing: 21; -Required one or two-person extensive or total assistance for toileting: 18; -Required one or two-person extensive or total assistance for dressing: 22; -Required two person assistance at all times for all care: 3; -Had behavioral… […]

• No harm, potential for more than minimal, patternF842Apr 7, 2023

  Based on interview and record review it was determined the facility failed to ensure care conferences were documented for 4 of 7 sampled residents (#s 10, 13, 20 and 21) reviewed for behaviors, unnecessary medications, care planning and nutrition. This placed residents at risk for incomplete records. Findings include: 1. Resident 13 was admitted to the facility in 2020 with diagnoses including chronic lung disease. A 2/16/23 Care Conference Form revealed the resident's weight was filled out and the resident's activity status was addressed. The sections of the form to indicate if the resident or resident's responsible party attended or was invited, who attended from the facility and if there were any identified concerns from the resident or responsible party were blank. […]