Nursing HomeInspections

Willow Creek Post Acute

Nursing home in Madras, OR

Medicare & Medicaid certified3★ overall (CMS)

Call (541) 475-2273Send a messageMap ↗

Public-record details

Address
175 Ne 16th Street, Madras, OR 97741
Phone
(541) 475-2273
Listed under
For-profit, No fines in 3 years
Medicare CCN
385181
Overall star rating
3 of 5 ★★★☆☆
Health inspection rating
5 of 5
Staffing rating
1 of 5
Quality measures rating
1 of 5
Certified beds
20
Average residents per day
18
Ownership
For-profit, limited Liability company
Legal business name
Sand Hollow, LLC
Chain
Kalesta Healthcare Group (19 facilities)
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
May 19, 1988
Changed ownership in last 12 months
No
Continuing care retirement community
No
Located inside a hospital
No
Resident or family council
Resident council
Sprinklers in all required areas
Yes

CMS certification number 385181. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Feb 12, 2026. CMS lists 17 health citations for this facility across its last three standard inspection cycles and complaint inspections (Jun 30, 2023 to Oct 9, 2024): 1 from complaint inspections, 1 at the “actual harm” level or higher.

InspectionCitationSeverity
Oct 9, 2024Ensure 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…
Pharmacy Service		E
Potential for more than minimal harm, pattern
Oct 9, 2024Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary		F
Potential for more than minimal harm, widespread
Jul 11, 2024Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care · complaint inspection		D
Potential for more than minimal harm, isolated
Jun 30, 2023Honor 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		D
Potential for more than minimal harm, isolated
Jun 30, 2023Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 30, 2023Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 30, 2023Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 30, 2023Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 30, 2023Post nurse staffing information every day.
Nursing and Physician Services		D
Potential for more than minimal harm, isolated
Jun 30, 2023Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service		D
Potential for more than minimal harm, isolated
Jun 30, 2023Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and…
Pharmacy Service		D
Potential for more than minimal harm, isolated
Jun 30, 2023Ensure 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		D
Potential for more than minimal harm, isolated

Showing the 12 most recent of 17. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records no fines or payment denials for this facility in the last three years.

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.