Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOW CREEK POST ACUTE
MADRAS, OR · 20 certified beds · Last Life Safety survey February 12, 2026
CMS Certification Number 385181 · first certified May 1988
Also on this campus
The same campus holds a state-licensed assisted living facilities, with their own state records on the Assisted Living Index: Willow Creek Assisted Living (175 Ne 16th Street) and Willow Creek Memory Care (175 Ne 16th Street). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by KALESTA HEALTHCARE GROUP · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OR
21 citations — more than 93% of the 128 certified nursing homes in OR. Compared within OR rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 8 months from now. This facility’s last Life Safety survey was February 2026. Facilities in OR are typically surveyed 15–17 months after the last one (median 16), measured over 188 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 21 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0924 Put firmly secured handrails on each side of hallways.
How that compares
Compared with the median facility in OR, and nationally. Surveyors differ markedly between states, so the OR figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in OR | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 30, 2023 | 6 |
| October 9, 2024 | 13 |
| February 12, 2026 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-10-09 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-10-09 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2023-06-30 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2026-02-12 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2024-10-09 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2023-06-30 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-10-09 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2024-10-09 |
What the citations cover
- Emergency Preparedness Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 4
- Smoke Deficiencies 4
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 12, 2026 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 1, 2026) |
October 9, 2024 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (November 28, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (November 28, 2024) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (November 28, 2024) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 28, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 28, 2024) |
June 30, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 10, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 10, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 10, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 10, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (August 10, 2023) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (August 10, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.