Willow Creek Post Acute
175 Ne 16th Street, Madras, OR 97741
Willow Creek Post Acute is a nursing home in Madras, Oregon. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 1 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (541) 475-2273
- Last standard health inspection
- February 12, 2026 (8 months ago)
- Certified beds
- 20
- Residents per day, on average
- 17
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Sand Hollow, LLC
- Chain
- Kalesta Healthcare Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Oregon average (17 vs 34).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
CMS update of October 8, 2026
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
CMS update of July 29, 2026
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
CMS update of May 27, 2026
Name
CMS lists a new name for this home. It was EAST CASCADE RETIREMENT COMMUNITY.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 5.7 to 0.9 hours per resident per day.
2 citations
Fire safety inspection on February 12, 2026
CMS lists this as a standard inspection.
Citation E0009. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on March 20, 2026.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 1, 2026.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
2 citations
Health inspection on October 9, 2024
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 1, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 1, 2024.
13 citations
Fire safety inspection on October 9, 2024
CMS lists this as a standard inspection.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on November 28, 2024.
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on November 28, 2024.
Citation E0020. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures including evacuation.
CMS lists it as corrected on November 28, 2024.
Citation E0026. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on November 28, 2024.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on November 28, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on November 28, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 28, 2024.
CMS has cited this home for K0353 2 times since 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on November 28, 2024.
CMS has cited this home for K0712 2 times since 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 28, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 28, 2024.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on November 28, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 28, 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on November 28, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 5.2 to 0.8 hours per resident per day.
1 citation
Health inspection on July 11, 2024
CMS lists this as a complaint inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on August 2, 2024.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of March 28, 2024
Name
CMS lists a new name for this home. It was EAST CASCADE RETIREMENT COMMUNITY, LLC.
CMS update of February 29, 2024
Fine
CMS changed the fine from June 30, 2023 from $69,030 to $69,901.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Fine
CMS changed the fine from June 30, 2023 from $106,200 to $69,030.
14 citations
Health inspection on June 30, 2023
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
29 of 128 Oregon homes (23%) got a citation at the actual harm level in 2023.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on July 19, 2023.
Citation F0727. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 10, 2023.
Citation F0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on September 27, 2022.
Citation F0924. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Put firmly secured handrails on each side of hallways.
CMS lists it as corrected on August 10, 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 10, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on August 10, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 10, 2023.
Citation F0691. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on August 10, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on August 10, 2023.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on August 10, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on August 10, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 10, 2023.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 10, 2023.
Citation F0808. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 10, 2023.
6 citations
Fire safety inspection on June 30, 2023
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on August 10, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 10, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 10, 2023.
Citation K0912. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on August 10, 2023.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on August 10, 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on August 10, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- KALESTA HEALTHCARE GROUP, LLC5% or greater direct ownership interest · 100% · since 12/18/2025
- CLAWSON, SCOTT5% or greater indirect ownership interest · 44% · since 12/18/2025
- WILLIAMS, RYAN5% or greater indirect ownership interest · 44% · since 03/01/2026
- CLAWSON, SCOTTIndirect ownership interest · not applicable · since 03/01/2026
- CLAWSON, SCOTTOperational/managerial control · not applicable · since 03/01/2026
- DELAMARTER, KRISTINEOperational/managerial control · not applicable · since 12/18/2025
- HULS, ERICOperational/managerial control · not applicable · since 12/18/2025
- WILLIAMS, RYANOperational/managerial control · not applicable · since 03/01/2026
Questions
When was Willow Creek Post Acute last inspected?
CMS lists February 12, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Willow Creek Post Acute have?
CMS lists 17 health citations since June 30, 2023. CMS also calls these deficiencies.
Has Willow Creek Post Acute been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Willow Creek Post Acute?
Its CMS overall star rating is 4 of 5.
Is Willow Creek Post Acute a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.