Willow Creek Post Acute
Madras, Jefferson County, Oregon · CCN 385181 · For-profit (LLC) · part of Kalesta Healthcare Group (19 facilities, chain average 2.4 stars)
CMS rates Willow Creek Post Acute 3 of 5 overall as of August 2026. 20 certified beds, 18 residents a day on average. 17 citations on record from the current inspection cycles, 1 involving actual harm; no fines on record.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★★★★ 5 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★☆☆☆☆ 1 of 5 |
| Quality: long-stay / short-stay | 1 / — of 5 |
Staffing
| Total nurse staffing | Too few residents or resident days to meet the minimum for this rating (CMS footnote 23) |
|---|
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2024-10-09 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-11-01 |
| 2024-10-09 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-11-01 |
| 2024-07-11 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-02 |
| 2023-06-30 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-07-19 |
| 2023-06-30 | 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. Nursing and Physician Services Deficiencies · tag F0727 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
E No actual harm, with potential for more than minimal harm; pattern | Past Non-Compliance 2022-09-27 |
| 2023-06-30 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · tag F0924 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0691 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | 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. Nutrition and Dietary Deficiencies · tag F0803 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
| 2023-06-30 | 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. Nutrition and Dietary Deficiencies · tag F0808 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-10 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Kalesta Healthcare Group, LLC Organization | 5% or greater direct ownership interest | 100% | 2025-12-18 |
| Clawson, Scott Individual | 5% or greater indirect ownership interest | 44% | 2025-12-18 |
| Williams, Ryan Individual | 5% or greater indirect ownership interest | 44% | 2026-03-01 |
| Clawson, Scott Individual | adp of the snf | — | 2026-03-01 |
| Delamarter, Kristine Individual | adp of the snf | — | 2025-12-18 |
| Huls, Eric Individual | adp of the snf | — | 2025-12-18 |
| Williams, Ryan Individual | adp of the snf | — | 2026-03-01 |
| Clawson, Scott Individual | indirect ownership interest | — | 2026-03-01 |
| Clawson, Scott Individual | operational/managerial control | — | 2026-03-01 |
| Delamarter, Kristine Individual | operational/managerial control | — | 2025-12-18 |
| Huls, Eric Individual | operational/managerial control | — | 2025-12-18 |
| Williams, Ryan Individual | operational/managerial control | — | 2026-03-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Willow Creek Post Acute.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Jefferson County.