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WILLOW CREEK POST ACUTE

175 NE 16TH STREET
MADRAS, OR 97741 · 5414752273 · Jefferson County

CMS Star Ratings

Overall★★★★★
Health inspection★★★★★
Staffing★★★★★
Quality measures★★★★★

Facility Facts

Certified beds20
OwnershipFor profit - Limited Liability company
State rank#79

By the numbers

17
Health citations (3 cycles)
0
Immediate-jeopardy (J/K/L)
1
Actual-harm (G/H/I)
$0
Federal fines (CMPs)
The trend: No citations in the most recent inspection cycle, an improvement over prior cycles.

Recent Health Citations

Oct 9, 2024 · Health survey · F-tag 0761
E — No actual harm
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.
Oct 9, 2024 · Health survey · F-tag 0812
F — No actual harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Jul 11, 2024 · Health survey · F-tag 0686
D — No actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Jun 30, 2023 · Health survey · F-tag 0808
D — No actual harm
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.
Jun 30, 2023 · Health survey · F-tag 0803
D — No actual harm
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.
Jun 30, 2023 · Health survey · F-tag 0758
D — No actual harm
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.
Jun 30, 2023 · Health survey · F-tag 0756
D — No actual harm
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.
Jun 30, 2023 · Health survey · F-tag 0732
D — No actual harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Jun 30, 2023 · Health survey · F-tag 0695
D — No actual harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Jun 30, 2023 · Health survey · F-tag 0691
D — No actual harm
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Jun 30, 2023 · Health survey · F-tag 0684
D — No actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Jun 30, 2023 · Health survey · F-tag 0677
D — No actual harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Jun 30, 2023 · Health survey · F-tag 0584
D — No actual harm
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.
Jun 30, 2023 · Health survey · F-tag 0924
E — No actual harm
Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
Jun 30, 2023 · Health survey · F-tag 0919
E — No actual harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Jun 30, 2023 · Health survey · F-tag 0727
E — No actual harm
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.
Jun 30, 2023 · Health survey · F-tag 0697
G — Actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Details
Correction status: Corrected Jul 19, 2023 — Deficient, Provider has date of correction
Inspection cycle: 3
Survey origin: Standard survey

Showing the 17 most recent citations. View the full inspection record on CMS Care Compare →

More facilities in Oregon →

How to read this page. Star ratings and citation counts come from the Centers for Medicare & Medicaid Services (CMS) Care Compare August 2026 dataset, covering the three most recent inspection cycles. Scope/severity letters: D–F no actual harm, G–I actual harm, J–L immediate jeopardy to resident health or safety.

Source: CMS Care Compare, August 2026 dataset. Updated quarterly. Figures come from public CMS records; contact info@theskilledreport.com for corrections.