Facility Watch Inspection records for every certified US nursing home

Willow Creek Post Acute

175 NE 16th Street
Madras, OR 97741
(541) 475-2273

CCN
385181
Certified beds
20
Ownership
For profit - Limited Liability company

Nurse staffing

5.76
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 1.19 hours per resident per day

Nursing staff turnover: 97% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected October 9, 2024

2 citations · Health
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected November 1, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected November 1, 2024

Inspected July 11, 2024

1 citation · from a complaint investigation · Health
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected August 2, 2024

Inspected June 30, 2023

14 citations · from a complaint investigation · Health
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0691 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0732 No actual harm with potential for more than minimal harm · Isolated

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0803 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 10, 2023
D
F0808 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 10, 2023
E
F0727 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected August 10, 2023
E
F0919 No actual harm with potential for more than minimal harm · Pattern

Make sure that a working call system is available in each resident's bathroom and bathing area.

Past Non-Compliance · corrected September 27, 2022
E
F0924 No actual harm with potential for more than minimal harm · Pattern

Put firmly secured handrails on each side of hallways.

Deficient, Provider has date of correction · corrected August 10, 2023
G
F0697 Actual harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected July 19, 2023

Penalties

DateTypeAmount
June 30, 2023Fine$69,901