Federal inspection record · CMS data as of October 1, 2026
Willow Creek Post Acute
175 Ne 16th Street, Madras, OR · (541) 475-2273
- Certified beds
- 20
- Residents per day
- 17
- Ownership
- For-Profit
- Chain
- Kalesta Healthcare Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 19, 1988
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Oregon.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★−1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Oregon homes
Willow Creek Post Acute carries 7 inspection points. That is fewer than 98% of Oregon's 126 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Oregon: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–14 pts
- 4★ 14–41 pts
- 3★ 41–65 pts
- 2★ 65–95.25 pts
- 1★ over 95.25 pts
Bars show every rated home in Oregon by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
17 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Provide safe, appropriate pain management for a resident who requires such services.
Everything else, by area of care
Quality of Life and Care5D
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Nutrition and Dietary3F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 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.
- 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.
Pharmacy Service3E
- 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.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 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.
Nursing and Physician Services2E
- 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.
- D
Post nurse staffing information every day.
Environmental2E
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
- E
Put firmly secured handrails on each side of hallways.
Resident Rights1D
- 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.
Inspection history
2026-02-12
0 health deficiencies · 2 fire-safety deficiencies
No concentrated health issue counts in this cycle.
2024-10-09
2 health deficiencies · 13 fire-safety deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2023-06-30
15 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 58 min of nursing staff time a day, 47 min of it from a registered nurse.
This home
4 h 58 min
Oregon average
5 h 8 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.1 pts better | 98.4% | 95.3% | 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.8 pts better | 1.6% | 2.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.4 pts worse | 5.3% | 4.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.4 pts better | 2.2% | 4.6% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.4 pts worse | 19.6% | 12.2% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication28.2 pts worse | 42.5% | 14.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased5.4 pts worse | 19.6% | 14.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.9 pts worse | 2.2% | 1.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection6.1 pts worse | 8.1% | 2.0% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence6 pts worse | 26.8% | 20.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.4 pts worse | 8.0% | 5.6% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine8.5 pts better | 94.3% | 85.8% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication5.3 pts worse | 6.7% | 1.4% | 1.5% |
·
Who owns and runs it
12 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Kalesta Healthcare Group, LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 19 facilities |
| Clawson, Scott | 5% Or Greater Indirect Ownership Interest · Individual | 44% | 34 facilities |
| Williams, Ryan | 5% Or Greater Indirect Ownership Interest · Individual | 44% | 28 facilities |
| Clawson, Scott | Indirect Ownership Interest · Individual | 0% | 34 facilities |
| Clawson, Scott | Operational/Managerial Control · Individual | 0% | 34 facilities |
| Clawson, Scott | Adp Of The SNF · Individual | 0% | 34 facilities |
| Delamarter, Kristine | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Delamarter, Kristine | Adp Of The SNF · Individual | 0% | 1 facilities |
| Huls, Eric | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Huls, Eric | Adp Of The SNF · Individual | 0% | 1 facilities |
| Williams, Ryan | Operational/Managerial Control · Individual | 0% | 28 facilities |
| Williams, Ryan | Adp Of The SNF · Individual | 0% | 28 facilities |
·
Fire safety
21 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Emergency Preparedness6F
- F
Include a process for Emergency Preparedness collaboration.
- 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
Conduct risk assessment and an All-Hazards approach.
- F
Conduct testing and exercise requirements.
Gas, Vacuum, and Electrical Systems5F
- 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
Have power receptacles that are properly grounded.
Smoke4F
- D
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous4F
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Have simulated fire drills held at unexpected times.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Egress2F
- F
Install emergency lighting that can last at least 1 1/2 hours.
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
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Other homes nearby
-
Regency Prineville Rehabilitation and Nursing Cent
Prineville, OR · Regency Pacific Management
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 56 min
- Fines
- $0
-
Regency Redmond Rehabilitation And Nursing Center
Redmond, OR · Regency Pacific Management
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 36 min
- Fines
- $0
-
Bend Transitional Care
Bend, OR · Cascadia Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 51 min
- Fines
- $0