Oregon › Jefferson County › Madras
Willow Creek Post Acute
175 Ne 16th Street, Madras, OR 97741
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Certified for 20 beds, Willow Creek Post Acute serves Madras in Jefferson County, Oregon and has taken Medicare and Medicaid residents since 1988.
CMS gives it 3 of 5 stars overall, equal to the Oregon median; the health inspection rating is 5, staffing 1 and quality measures 1.
Inspectors recorded 17 health deficiencies across the three most recent survey cycles (0, 2, 15 by cycle, most recent first), 1 of them at the actual-harm or immediate-jeopardy level. That is 85.0 per 100 beds, more than the state median of 40.0.
CMS lists no fines or payment denials against the facility in the period covered.
Compared with county, state and nation
| Measure | This facility | Jefferson Co. median | Oregon median | US average |
|---|---|---|---|---|
| Overall star rating | 3 | 3 | 3 | 3.0 |
| Health citations, 3 cycles | 17 | 17 | 32 | 28.7 |
| Citations per 100 beds | 85.0 | 85.0 | 40.0 | 26.8 |
| Total nurse hours per resident day | — | — | 5.0 | 3.9 |
| RN hours per resident day | — | — | 0.6 | 0.7 |
| Nursing staff turnover | — | — | 45.9% | 45.8% |
| Fines listed | $0 | $0 | $4,194 | — |
County and state figures are medians across facilities (1 in the county, 128 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Oregon average per facility for the same cycle, as published by CMS. Standard health survey dates: 12 Feb 2026, 9 Oct 2024.
Severity mix: G ×1 D ×11 E ×4 F ×1
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 9 Oct 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 1 Nov 2024 |
| 9 Oct 2024 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Standard survey | 1 Nov 2024 |
| 11 Jul 2024 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Complaint investigation | 2 Aug 2024 |
| 30 Jun 2023 | F0697 | Provide safe, appropriate pain management for a resident who requires such services. | G | Standard survey | 19 Jul 2023 |
| 30 Jun 2023 | F0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | E | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. | E | Standard survey | 27 Sep 2022 |
| 30 Jun 2023 | F0924 | Put firmly secured handrails on each side of hallways. | E | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0732 | Post nurse staffing information every day. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | D | Standard survey | 10 Aug 2023 |
| 30 Jun 2023 | F0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | D | Standard survey | 10 Aug 2023 |
Penalties
CMS lists no fines or payment denials for this facility in the period covered.
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Oregon average. Turnover: nursing staff —, RNs —; — administrators left in the reporting year.
Quality measures
| Measure | Residents | This facility | Oregon median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 15.2% | 14.7% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 4.5% | 0.7% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 9.4% | 1.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.6% | 2.3% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 5.6% | 1.0% | 1.0% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.8% | 5.3% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 48.8% | 13.5% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, limited liability company. Legal business name: Sand Hollow, Llc. Chain: Kalesta Healthcare Group (19 facilities).
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Kalesta Healthcare Group, LLC | 5% or greater direct ownership interest | 100% | 12/18/2025 |
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Questions and answers
How many deficiencies has Willow Creek Post Acute been cited for?
17 health deficiencies across the three most recent survey cycles, 1 at the actual-harm or immediate-jeopardy level. The Oregon median is 32 per facility.
Has Willow Creek Post Acute been fined?
CMS lists no fines against the facility in the period covered.
How does staffing at Willow Creek Post Acute compare?
CMS does not report staffing hours for this facility.
Who operates Willow Creek Post Acute?
It is part of the Kalesta Healthcare Group chain. Ownership type is for-profit, limited liability company. Organisations in the CMS ownership record include Kalesta Healthcare Group, LLC. Individual owners and managers are not listed on this site.
When was Willow Creek Post Acute last inspected?
The most recent survey or investigation in the CMS record is dated 9 Oct 2024; the most recent standard health survey was 12 Feb 2026.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.