Willow Creek Healthcare Center
Clovis, Fresno County, California · CCN 555652 · For-profit (LLC) · part of Pacs Group (274 facilities, chain average 2.9 stars)
CMS rates Willow Creek Healthcare Center 3 of 5 overall as of August 2026. 159 certified beds, 153 residents a day on average. 62 citations on record from the current inspection cycles, 7 involving actual harm; 2 fines totalling $25,045 and 1 payment denial.
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 | ★★☆☆☆ 2 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / 5 of 5 |
Staffing
| Total nurse staffing | 4.18486 hours per resident per day |
|---|---|
| Registered nurses | 0.45595 hours per resident per day |
| Weekend total | 3.87801 hours per resident per day |
| Nursing staff turnover | 59.7% (registered nurses 42.9%) |
| Administrators who left | 0 |
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 |
|---|---|---|---|
| 2026-05-14 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-05 |
| 2026-05-14 complaint survey |
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 2026-06-05 |
| 2026-01-05 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-01-16 |
| 2025-09-24 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-10-06 |
| 2025-06-02 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-18 |
| 2025-05-07 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-06-04 |
| 2025-04-04 | 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 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | 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 2025-05-01 |
| 2025-04-04 | 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 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · tag F0814 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · tag F0557 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-04-04 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2024-12-26 complaint survey |
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 | Deficient, Provider has date of correction 2025-01-10 |
| 2024-10-01 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-10-16 |
| 2024-06-21 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-25 |
| 2024-06-21 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-25 |
| 2024-06-07 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-07-31 |
| 2024-06-07 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-31 |
| 2024-05-14 complaint survey |
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-20 |
| 2024-04-29 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-17 |
| 2024-03-07 | 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 2024-03-25 |
| 2024-03-07 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · tag F0814 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-03-25 |
| 2024-03-07 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-25 |
| 2024-03-07 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-25 |
| 2024-03-07 | 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 2024-03-25 |
| 2023-10-06 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-22 |
| 2023-08-30 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-16 |
| 2023-08-09 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-20 |
| 2023-08-09 complaint survey |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-20 |
| 2023-08-09 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-20 |
| 2019-05-17 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
H Actual harm that is not immediate jeopardy; pattern | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
H Actual harm that is not immediate jeopardy; pattern | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | 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 2019-08-07 |
| 2019-05-17 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · tag F0838 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · tag F0867 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · tag F0802 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | 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 2019-08-07 |
| 2019-05-17 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Nursing and Physician Services Deficiencies · tag F0711 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | 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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-08-07 |
| 2019-05-17 | 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 2019-08-07 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-01-05 | Fine | $15,935 |
| 2025-09-24 | Fine | $9,110 |
| 2025-05-07 | Payment denial for 6 days from 2025-06-12 | — |
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 |
|---|---|---|---|
| Providence Group Inc. Organization | 5% or greater direct ownership interest | 100% | 2019-03-11 |
| Sood, Pawan Individual | contracted managing employee | — | 2020-03-01 |
| Apt, Frederick Individual | corporate officer | — | 2024-01-01 |
| Mitchell, John Individual | corporate officer | — | 2024-01-01 |
| Cantwell, Kalan Individual | w-2 managing employee | — | 2024-04-01 |
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 Healthcare Center.
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 Fresno County.