Willow Creek Post Acute
175 Ne 16th Street, Madras, OR 97741 · Jefferson County · (541) 475-2273
20 certified beds, about 18 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1988
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
5 of 5
Staffing
1 of 5
CMS note: This facility did not submit staffing data.
Quality measures
1 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385181 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on February 12, 2026, inspectors cited 0 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 17 health citations since June 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
CMS links it to Kalesta Healthcare Group, an affiliated group of 19 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1406/23
107/24
210/24
002/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
4E
1F
Potential for minimal harm
0A
0B
0C
February 12, 2026Standard inspection · 0 citations
October 9, 2024Standard inspection · 2 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to monitor and maintain refrigerator and dishwasher temperatures for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for food borne illnesses.
- E 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 1 of 2s medication cart observed for secure medication carts. This placed residents at risk for misappropriation of medications and adverse medication consequences.
July 11, 2024Complaint inspection · 1 citation
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify a physician and obtain orders for a worsening pressure ulcer for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. This placed resident at risk for worsening wounds.
June 30, 2023Standard inspection · 14 citations
- G Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed resident's severe pain for 1 of 1 sampled resident (#18) reviewed for pain management. This resulted in Resident 18 having unrelieved, unmanageable pain and treatment at the hospital Emergency Department.
- E 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 16 of 30 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments.
- E Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure call lights were functioning for 1 of 1 facility and 2 of 3 sampled residents (#s 22 and 23). This placed residents at risk for delayed care and unmet needs.
- E Put firmly secured handrails on each side of hallways.
Inspectors wroteBased on observation and interview it was determined the facility failed to provide secured handrails in all corridors for 2 of 2 halls reviewed for environment. This placed residents at risk for accidents.
- D 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.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure resident equipment was maintained and sanitary for 2 of 3 sampled residents (#s 1, and 16) and flooring was safe in the living room reviewed for environment. This placed residents at risk for injury and unhomelike environment.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming and nail care for 2 of 5 sampled residents (#s 3 and 8) reviewed for ADLs and hospice. This placed residents at risk for lack of grooming and hygiene.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed and implemented for 3 of 5 sampled residents (#s 4, 12 and 23) reviewed for medications. This placed residents at risk for adverse side effects of medications.
- D Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed and implemented for 1 of 1 sampled resident (#21) reviewed for ostomy care. This placed residents at risk for skin breakdown.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident respiratory orders were accurate and equipment was maintained for 1 of 1 sampled resident (#3) reviewed for respiratory care. This placed residents at risk for respiratory issues.
- D Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure accurate staffing information was posted for 7 of 30 days reviewed for staffing reports. This placed residents and the public at risk for lack of staffing information.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 2 of 5 sampled residents (#s 5 and 15) reviewed for medications. This placed residents at risk for medication complications.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide adequate behavior monitoring for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for increased behaviors and adverse side effects.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to honor residents religious food preferences for 1 of 7 sampled residents (#23) reviewed for food and religious choices. This placed residents at risk for not honoring religious choices.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow therapeutic diet recommendations for 1 of 7 sampled residents (#23) reviewed for food and therapeutic diet. This placed residents at risk for weight loss.
Fire safety inspections
21 fire safety citations on file: 2 on February 12, 2026, 13 on October 9, 2024, 6 on June 30, 2023.
Every fire safety citation21 citations
- F Include a process for Emergency Preparedness collaboration.
- D Provide properly protected cooking facilities.
- F Conduct risk assessment and an All-Hazards approach.
- F Address subsistence needs for staff and patients.
- F Establish policies and procedures including evacuation.
- F Establish roles under a Waiver declared by secretary.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Meet requirements for the installation and maintenance of electrical systems.
- D Ensure proper usage of power strips and extension cords.
- D Have proper medical gas storage and administration areas.
- F Conduct testing and exercise requirements.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have power receptacles that are properly grounded.
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 5.03 | 3.86 |
| Registered nurses | not reported | 0.72 | 0.69 |
| All nursing staff on weekends | not reported | 4.51 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | not reported | 47.4% | 45.8% |
| Registered nurse turnover | not reported | 51.6% | 42.9% |
| Administrators who left | not reported |
CMS note on this home's staffing data: This facility did not submit staffing data.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In October to December 2025, nursing staff hours per resident were 6.74 on weekdays and 5.29 on weekends, 22% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.3% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.68 in April to June 2025 to 6.33 in October to December 2025.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Oct to Dec 2025 | 6.33 | 1.31 | 6.74 | 5.29 | 8.3% | 0 of 92 | 17 |
| Jul to Sep 2025 | 0.94 | 0.32 | 1.07 | 0.62 | 68.3% | 23 of 92 | 19 |
| Apr to Jun 2025 | 5.68 | 1.10 | 6.05 | 4.75 | 10.8% | 0 of 91 | 18 |
| United States, Oct to Dec 2025 | 3.76 | 0.62 | 3.93 | 3.34 | 5.3% | 0.5% of days | |
| Oregon, Oct to Dec 2025 | 5.00 | 0.65 | 5.20 | 4.47 | 7.3% | 0.3% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.2 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 4.5 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 9.4 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.6 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 5.6 | 1.4 | 1.6 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.8 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 48.8 | 13.9 | 15.4 |
Owners and operators
Legal business name: SAND HOLLOW, LLC. CMS links this home to Kalesta Healthcare Group, a group of 19 nursing homes averaging 2.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Kalesta Healthcare Group, LLC | 5% or greater direct ownership interest | Organization | 100% | 12/18/2025 |
| Clawson, Scott | 5% or greater indirect ownership interest | Individual | 44% | 12/18/2025 |
| Williams, Ryan | 5% or greater indirect ownership interest | Individual | 44% | 03/01/2026 |
| Clawson, Scott | Indirect ownership interest | Individual | 03/01/2026 | |
| Clawson, Scott | Operational/managerial control | Individual | 03/01/2026 | |
| Delamarter, Kristine | Operational/managerial control | Individual | 12/18/2025 | |
| Huls, Eric | Operational/managerial control | Individual | 12/18/2025 | |
| Williams, Ryan | Operational/managerial control | Individual | 03/01/2026 | |
| Clawson, Scott | Adp of the SNF | Individual | 03/01/2026 | |
| Delamarter, Kristine | Adp of the SNF | Individual | 12/18/2025 | |
| Huls, Eric | Adp of the SNF | Individual | 12/18/2025 | |
| Williams, Ryan | Adp of the SNF | Individual | 03/01/2026 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 6 problems in this area, most recently on July 11, 2024: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 3 problems in this area, most recently on October 9, 2024: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on October 9, 2024: "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."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 2 problems in this area, most recently on June 30, 2023: "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."
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Willow Creek Post Acute's Medicare star rating?
- CMS rates Willow Creek Post Acute 3 out of 5 stars overall, with 5 for health inspections, 1 for staffing and 1 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Willow Creek Post Acute get at its last inspection?
- 0 health deficiencies at the standard inspection on February 12, 2026. The Oregon average is 9.2.
- Has Willow Creek Post Acute been fined?
- CMS lists no fines in the last three years.
- Does Willow Creek Post Acute accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Willow Creek Post Acute?
- CMS lists 12 owners and managers, and links the home to Kalesta Healthcare Group. Legal business name: SAND HOLLOW, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.