Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B-
Grade
46
Score
CMS Ratings
12.3/22
Staffing Quality
0.0/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
6.0/10

Current Availability Estimate

Occupancy Rate88.0%
20
Total Beds
18
Occupied
2
Available

Basic Information

Address:

175 NE 16TH STREET

MADRAS, OR 97741

Number of Beds:

20

Estimated Occupancy:

88% (~2 available)

Chain:

KALESTA HEALTHCARE GROUP

Quality Ratings

Overall Rating:3/5 Stars
Health Inspection:5/5 Stars
Staffing Rating:1/5 Stars
Quality Measures:1/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

385181

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Detailed staffing data not available for this facility.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

74

Inspections

4

High

6

Oct 9, 2024 - Health Survey

4 deficiencies cited

Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Nov 1, 2024
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: Nov 1, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Nov 1, 2024
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: Nov 1, 2024

Jul 11, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Aug 2, 2024From Complaint
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Aug 2, 2024From Complaint

Jun 30, 2023 - Health Survey

28 deficiencies cited

High - Widespread PatternTag F0697

Quality of Life and Care Deficiencies

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

Corrected: Jul 19, 2023From Complaint
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0756

Pharmacy Service Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0808

Nutrition and Dietary Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0919

Environmental Deficiencies

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

Corrected: Jun 30, 2023From Complaint
Medium - PatternTag F0924

Environmental Deficiencies

Put firmly secured handrails on each side of hallways.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0727

Nursing and Physician Services Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0691

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0691

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

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

Corrected: Aug 10, 2023From Complaint
High - Widespread PatternTag F0697

Quality of Life and Care Deficiencies

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

Corrected: Jul 19, 2023From Complaint
Medium - PatternTag F0727

Nursing and Physician Services Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0756

Pharmacy Service Deficiencies

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

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0808

Nutrition and Dietary Deficiencies

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.

Corrected: Aug 10, 2023From Complaint
Medium - PatternTag F0919

Environmental Deficiencies

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

Corrected: Jun 30, 2023From Complaint
Medium - PatternTag F0924

Environmental Deficiencies

Put firmly secured handrails on each side of hallways.

Corrected: Aug 10, 2023From Complaint

May 6, 2022 - Health Survey

40 deficiencies cited

Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0867

Administration Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0888

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

Corrected: Jun 25, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Jun 25, 2022
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0582

Resident Rights Deficiencies

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

Corrected: Jun 25, 2022
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

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.

Corrected: Jun 25, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
High - Widespread PatternTag F0692

Quality of Life and Care Deficiencies

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

Corrected: Jul 20, 2022
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0710

Nursing and Physician Services Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

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.

Corrected: Jun 25, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0825

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0867

Administration Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0888

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

Corrected: Jun 25, 2022
Medium - PatternTag F0582

Resident Rights Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Jun 25, 2022
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jun 25, 2022
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jun 25, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

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.

Corrected: Jun 25, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
High - Widespread PatternTag F0692

Quality of Life and Care Deficiencies

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

Corrected: Jul 20, 2022
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0710

Nursing and Physician Services Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

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.

Corrected: Jun 25, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Jun 25, 2022
Medium - PatternTag F0825

Quality of Life and Care Deficiencies

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

Corrected: Jun 25, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

No penalties or payment denials in the past 3 years

Key Highlights

🏆
Clean Safety Record
No recent penalties or high-severity deficiencies
🏢
Part of Healthcare Chain
KALESTA HEALTHCARE GROUP

Frequently Asked Questions

What is the quality rating for WILLOW CREEK POST ACUTE?

WILLOW CREEK POST ACUTE has an overall CMS rating of 3 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

WILLOW CREEK POST ACUTE has 20 certified beds. The facility averages 18 residents per day, with an occupancy rate of approximately 88%.

What type of ownership does this facility have?

This facility is for profit - limited liability company owned. It is part of the KALESTA HEALTHCARE GROUP network.

How can I contact WILLOW CREEK POST ACUTE?

You can call WILLOW CREEK POST ACUTE at (541)475-2273. The facility is located at 175 NE 16TH STREET, MADRAS, OR 97741.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

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