nursing home in Madras, OR
Willow Creek Post Acute
175 NE 16th Street, Madras, OR 97741 · (541) 475-2273
★★★★★3
Average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★5
- Staffing★★★★★1
- Quality measures★★★★★1
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Willow Creek Post Acute at a glance
Willow Creek Post Acute is a 20-bed for-profit nursing home in Madras, Oregon (Jefferson County).
CMS gives it 3 out of 5 stars on its overall star rating, close to the Oregon average of 3.1.
Its most recent standard health inspection (February 12, 2026) found 0 health citations. The Oregon average is 9.2.
It has not received a federal fine in the past three years.
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Limited Liability Company
- Beds
- 20
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Kalesta Healthcare Group
- Medicare-certified since
- May 19, 1988
- Resident/family council
- Resident
- County
- Jefferson County
- CMS Certification Number
- 385181
Ratings
| Measure | This facility | Oregon avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 3 / 5 | 3.1 / 5 | 3 / 5 | Average |
| Health inspection rating ⓘ (higher is better) | 5 / 5 | 2.8 / 5 | 2.8 / 5 | Better |
| Staffing rating ⓘ (higher is better) | 1 / 5 | 3.9 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 1 / 5 | 3.5 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 1 / 5 | 3.4 / 5 | 3.8 / 5 | Worse |
Inspections
| Measure | This facility | Oregon avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 0 | 9 | 9 | Better |
| Citations from complaint investigations (latest cycle) (lower is better) | 0 | 2 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 7 | 71.8 | 80.6 | Better |
Penalties
| Measure | This facility | Oregon avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
| Total fines in the past 3 years (lower is better) | $0 | $27,522 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
Size
| Measure | This facility | Oregon avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 20 | 83 | 107 | |
| Average residents per day | 18 | 58 | 86 | |
| Occupancy | 88% | 71.9% | 80.9% |
Long-stay residents
| Measure | This facility | Oregon avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 1.6% | 2.4% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 6.8% | 5.8% | 4.6% | Worse |
| Long-stay residents given antipsychotic medication (lower is better) | 48.8% | 13.9% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 9.4% | 2% | 1.6% | Worse |
| Long-stay residents with a catheter left in the bladder (lower is better) | 4.5% | 1.4% | 0.8% | Worse |
| Long-stay residents needing more help with daily activities (lower is better) | 15.2% | 14.9% | 13.9% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 2.1% | 4.7% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 5% | 4.9% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 22.9% | 12.4% | 19.5% | Worse |
| Long-stay residents with new or worse incontinence (lower is better) | 26.4% | 21.8% | 19% | Worse |
| Long-stay residents given a pneumonia vaccine (higher is better) | 98.4% | 95.2% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Oregon avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 5.6% | 1.4% | 1.6% | Worse |
| Short-stay residents given a flu vaccine (higher is better) | 90.5% | 81.2% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 97.1% | 85.6% | 82% | Better |
Inspection citations
State inspectors cited this home for 17 health deficiencies and 21 fire safety deficiencies in the inspection records CMS currently publishes. 1 citation involved actual harm.
| Date | Citation | Severity | Status |
|---|---|---|---|
| February 12, 2026 Fire safety | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies · Tag E0009 | F Potential harm, widespread | Corrected March 20, 2026 |
| February 12, 2026 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | D Potential harm, isolated | Corrected April 1, 2026 |
| October 9, 2024 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Tag E0006 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Tag E0015 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Establish policies and procedures including evacuation. Emergency Preparedness Deficiencies · Tag E0020 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies · Tag E0026 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0923 | D Potential harm, isolated | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | D Potential harm, isolated | Corrected November 28, 2024 |
| October 9, 2024 Fire safety | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0911 | D Potential harm, isolated | Corrected November 28, 2024 |
| October 9, 2024 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected November 1, 2024 |
| October 9, 2024 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected November 1, 2024 |
| July 11, 2024 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected August 2, 2024 |
| June 30, 2023 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected August 10, 2023 |
| June 30, 2023 Fire safety | Have power receptacles that are properly grounded. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0912 | F Potential harm, widespread | Corrected August 10, 2023 |
| June 30, 2023 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected August 10, 2023 |
| June 30, 2023 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | F Potential harm, widespread | Corrected August 10, 2023 |
| June 30, 2023 Fire safety | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Tag K0223 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | G Actual harm, isolated | Corrected July 19, 2023 |
| June 30, 2023 Standard | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Tag F0919 | E Potential harm, pattern | Corrected September 27, 2022 |
| June 30, 2023 Standard | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · Tag F0924 | E Potential harm, pattern | Corrected August 10, 2023 |
| June 30, 2023 Standard | 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. Nursing and Physician Services Deficiencies · Tag F0727 | E Potential harm, pattern | Corrected August 10, 2023 |
| June 30, 2023 Standard | 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. Pharmacy Service Deficiencies · Tag F0758 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | 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. Nutrition and Dietary Deficiencies · Tag F0803 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | 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. Nutrition and Dietary Deficiencies · Tag F0808 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | 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. Resident Rights Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0691 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Tag F0732 | D Potential harm, isolated | Corrected August 10, 2023 |
| June 30, 2023 Standard | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Tag F0756 | D Potential harm, isolated | Corrected August 10, 2023 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports no federal fines or payment denials in the past three years.
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| KALESTA HEALTHCARE GROUP, LLC Organization | 5% or greater direct ownership interest | 100% | 12/18/2025 |
| CLAWSON, SCOTT Individual | 5% or greater indirect ownership interest | 44% | 12/18/2025 |
| WILLIAMS, RYAN Individual | 5% or greater indirect ownership interest | 44% | 03/01/2026 |
| CLAWSON, SCOTT Individual | adp of the snf | NOT APPLICABLE | 03/01/2026 |
| DELAMARTER, KRISTINE Individual | adp of the snf | NOT APPLICABLE | 12/18/2025 |
| HULS, ERIC Individual | adp of the snf | NOT APPLICABLE | 12/18/2025 |
| WILLIAMS, RYAN Individual | adp of the snf | NOT APPLICABLE | 03/01/2026 |
| CLAWSON, SCOTT Individual | indirect ownership interest | NOT APPLICABLE | 03/01/2026 |
| CLAWSON, SCOTT Individual | operational/managerial control | NOT APPLICABLE | 03/01/2026 |
| DELAMARTER, KRISTINE Individual | operational/managerial control | NOT APPLICABLE | 12/18/2025 |
| HULS, ERIC Individual | operational/managerial control | NOT APPLICABLE | 12/18/2025 |
| WILLIAMS, RYAN Individual | operational/managerial control | NOT APPLICABLE | 03/01/2026 |
Other nursing homes near Willow Creek Post Acute
Regency Prineville Rehabilitation and Nursing Cent
950 NE Elm Street, Prineville, OR 97754 · 26.6 mi
For-profit · 44 beds · Part of Regency Pacific Management
- CMS high performer
★★★★★5Much above averageRegency Redmond Rehabilitation and Nursing Center
3025 SW Reservoir Drive, Redmond, OR 97756 · 27.2 mi
For-profit · 50 beds · Part of Regency Pacific Management
- CMS high performer
★★★★★5Much above average
Frequently asked questions
What is Willow Creek Post Acute's rating?
Willow Creek Post Acute has 3 out of 5 stars on the CMS overall star rating. The average for Oregon nursing homes is 3.1 stars.
How many inspection citations did Willow Creek Post Acute receive?
Its most recent standard health inspection found 0 citations, compared with a Oregon average of 9.2. Every citation is listed on this page with its severity.
Does Willow Creek Post Acute accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Willow Creek Post Acute?
It is for profit - limited liability company and part of Kalesta Healthcare Group. The ownership section on this page lists the owners and managers reported to CMS.
Where is Willow Creek Post Acute and how do I contact it?
Willow Creek Post Acute is at 175 NE 16th Street, Madras, OR 97741. Phone: (541) 475-2273.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.