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Public Record

Willow Creek Post Acute

Nursing HomeMadras, ORCMS 385181
66 citations on record

From CMS

Facility profile

CMS overall rating
3 / 5

*CMS Five-Star

Certified beds
20

*CMS

Avg. residents per day
16.6

*CMS

Inspection record

On record from CMS

Citations on record
66

*CMS

Inspections on file
8

*CMS

Last inspection
2026-02-12

*CMS

Citations

66 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0009Generalpotential for harm

    Include a process for Emergency Preparedness collaboration.

  • 0911Generalpotential for harm

    Meet requirements for the installation and maintenance of electrical systems.

  • 0761Generalpotential for harm

    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.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0026Generalpotential for harm

    Establish roles under a Waiver declared by secretary.

  • 0020Generalpotential for harm

    Establish policies and procedures including evacuation.

  • 0015Generalpotential for harm

    Address subsistence needs for staff and patients.

  • 0006Generalpotential for harm

    Conduct risk assessment and an All-Hazards approach.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0686Generalpotential for harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0924Generalpotential for harm

    Put firmly secured handrails on each side of hallways.

  • 0584Generalpotential for harm

    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.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0691Generalpotential for harm

    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0697Seriousactual harm

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0727Generalpotential for harm

    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.

  • 0732Generalpotential for harm

    Post nurse staffing information every day.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758Generalpotential for harm

    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.

  • 0803Generalpotential for harm

    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.

  • 0808Generalpotential for harm

    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.

  • 0919Generalpotential for harm

    Make sure that a working call system is available in each resident's bathroom and bathing area.

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

  • 0223Generalpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0741Generalpotential for harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  • 0912Generalpotential for harm

    Have power receptacles that are properly grounded.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0222Generalpotential for harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0342Generalpotential for harm

    Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0912Generalpotential for harm

    Have power receptacles that are properly grounded.

  • 0803Generalpotential for harm

    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.

  • 0725Generalpotential for harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0710Generalpotential for harm

    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

  • 0697Generalpotential for harm

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0692Seriousactual harm

    Provide enough food/fluids to maintain a resident's health.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0688Generalpotential for harm

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  • 0686Seriousactual harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0679Generalpotential for harm

    Provide activities to meet all resident's needs.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0636Generalpotential for harm

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0582Generalpotential for harm

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0825Generalpotential for harm

    Provide or get specialized rehabilitative services as required for a resident.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0867Generalpotential for harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0888Generalpotential for harm

    Ensure staff are vaccinated for COVID-19

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Willow Creek Post Acute?
Willow Creek Post Acute is a Medicare- and Medicaid-certified nursing home in Madras, OR, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 385181.
What is the CMS rating for Willow Creek Post Acute?
Willow Creek Post Acute has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Willow Creek Post Acute have?
Willow Creek Post Acute is certified for 20 beds. It serves an average of 16.6 residents per day.
How many citations does Willow Creek Post Acute have?
Willow Creek Post Acute has 66 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Willow Creek Post Acute last inspected?
Willow Creek Post Acute was last inspected on February 12, 2026. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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