Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Creek Post Acute during CMS and state inspections, most recent first.
The facility did not properly monitor and maintain refrigerator and dishwasher temperatures, as evidenced by incomplete temperature logs. Records were missing for periods before 9/17 and after 10/5, with the dishwasher temperature not documented on 10/5. The Dietary Manager confirmed the logs were not up to date, posing a risk for foodborne illnesses.
The facility failed to secure medications and biologicals, as a medication cart was repeatedly found unlocked and unattended near the nurses' station. On separate occasions, medications, including Omeprazole and resident-specific bubble-pack cards, were left unsecured. RNs confirmed these lapses, and the DNS acknowledged the requirement for securing the cart when unattended.
A resident with dementia and peripheral vascular disease was admitted with a Stage 1 pressure ulcer on the right heel, which worsened to an unstageable ulcer with necrotic tissue. The facility failed to notify the physician of the worsening condition from 2/9/24 to 2/18/24, leading to hospitalization. Staff interviews revealed inconsistent interventions and lack of communication about the resident's deteriorating condition.
Incomplete Temperature Monitoring in Kitchen
Penalty
Summary
The facility failed to adequately monitor and maintain the temperatures of the refrigerator and dishwasher in the kitchen, which is crucial for ensuring sanitary conditions and preventing foodborne illnesses. The kitchen Equipment Temp Log was reviewed, revealing that temperature records were only available from 9/17/24 to 9/30/24, with no records prior to 9/17/24. Additionally, while temperatures were documented from 10/1/24 to 10/4/24, the dishwasher temperature was not recorded on 10/5/24, and no temperatures were documented after this date. On 10/8/24, the Dietary Manager acknowledged that the temperature logs were incomplete and not up to date, indicating a lapse in the facility's monitoring procedures.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured and accessible only to authorized personnel, as observed in one of the two medication carts. On multiple occasions, the medication cart near the nurses' station was found unlocked and unattended by staff. Specifically, on 10/7/24, the cart was left unlocked and unattended, which was confirmed by a registered nurse (RN). On 10/8/24, a bottle of Omeprazole and bubble-pack cards containing medications for a resident were left on top of the medication cart, unattended by staff. This was again confirmed by an RN. On 10/9/24, the medication cart was once more found unlocked and unattended, with confirmation from another RN. The Director of Nursing Services (DNS) acknowledged that the medication cart should be secured when unattended.
Failure to Notify Physician of Worsening Pressure Ulcer
Penalty
Summary
The facility failed to notify a physician and obtain orders for a worsening pressure ulcer for a resident, which placed the resident at risk for worsening wounds. The resident was admitted with a Stage 1 pressure ulcer on the right heel, which was initially managed with wound care orders. However, the care plan lacked information regarding the resident's risk for pressure ulcers and interventions to address this risk. Over time, the wound worsened significantly, progressing to a Stage 3 pressure ulcer with suspected cellulitis and eventually becoming unstageable with 100% necrotic tissue. Despite the worsening condition of the wound, there was no indication that staff communicated or notified the physician of the changes from 2/9/24 through 2/18/24. The resident's condition deteriorated, leading to hospitalization due to the worsening wound. Interviews with staff revealed a lack of consistent interventions, such as the use of boot protectors or wedges, and a failure to report the worsening condition to the appropriate medical personnel. The deficiency was further highlighted by the lack of awareness among staff regarding the new blister on the top of the resident's foot and the absence of communication with the physician about the worsening wound. The resident was eventually sent to the hospital and returned on hospice services with diagnoses including atherosclerosis, venous insufficiency, and dry gangrene.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madras
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Prineville Rehabilitation And Nursing Cent | 26.6 mi | ★★★★★ | 4 | 0 |
| Regency Redmond Rehabilitation And Nursing Center | 27.2 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.