Nursing homeActive
Willow Creek Post Acute
175 Ne 16th Street, Madras, OR 97741541475227320 certified beds · 18 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
4
since 2023
Deficiencies
17
● 0● 16● 1
Penalties · 3 yrs
—
none on file
Last survey
2026-02-12
Standard
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 5
Staffing 1
Quality 1
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Oregon Department of Human Services · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-02-12 | Standard | 000 | CMS-2567 (Care Compare) | — |
| 2024-10-09 | Standard | 020 | CMS-2567 (Care Compare) | — |
| 2024-07-11 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-06-30 | Standard | 0131 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Oregon Department of Human Services publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 385181-20241009-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 385181-20241009-F812
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-02Record 385181-20240711-F686
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-07-19Record 385181-20230630-F697
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F584
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F684
F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F691
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F695
F727Have 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.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F727
F732Post nurse staffing information every day.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F732
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F756
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F758
F803Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F803
F808Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F808
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-09-27Record 385181-20230630-F919
F924Put firmly secured handrails on each side of hallways.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-10Record 385181-20230630-F924
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Oregon | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 6.8% | 5.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.6% | 2.4% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 48.8% | 13.9% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 9.4% | 2.0% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 15.2% | 14.9% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 2.1% | 4.7% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 22.9% | 12.4% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Kalesta Healthcare Group, LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Clawson, Scott Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% | — | — |
| Williams, Ryan Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% | — | — |
| Clawson, Scott Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Delamarter, Kristine Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Huls, Eric Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Williams, Ryan Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Clawson, Scott Individual | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Clawson, Scott Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Delamarter, Kristine Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Huls, Eric Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Williams, Ryan Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Kalesta Healthcare Group — 19 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Oregon.
No county cost figures on file for Jefferson.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Regency Redmond Rehabilitation And Nursing Center Redmond | 27.2 mi | 2026-01-16 | 0180 |
| Regency Prineville Rehabilitation and Nursing Cent Prineville | 26.6 mi | 2026-01-16 | 040 |
| Bend Transitional Care Bend | 40.6 mi | 2025-06-27 | 030 |
| Pilot Butte Rehabilitation Center Bend | 41.0 mi | 2026-06-24 | 0361 |
| Regency Care Of Central Oregon Bend | 42.0 mi | 2025-12-05 | 070 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |