Willow Creek Post Acute

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

41.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.

• Actual harm · G2023-06-30 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed resident's severe pain for 1 of 1 sampled resident (#18) reviewed for pain management. This resulted in Resident 18 having unrelieved, unmanageable pain and treatment at the hospital Emergency Department. Findings include: Resident 18 admitted to the facility in 4/2023 with diagnoses including chronic pain and osteoarthritis. A 5/10/23 Behavioral Symptoms and Pain CAA revealed Resident 18 had episodes of cursing, yelling and became agitated at staff notably when she/he had extreme pain while pending hip surgery. When Resident 18's pain was managed she/he was in a pleasant mood. A message was sent to the IDT (Interdisciplinary Team) and requested a follow up with the physician for pain management improvement. A 5/13/23 physician order directed staff to administer oxycodone-acetaminophen 5-325 mg one tablet by mouth every four hours for chronic pain. A review of Resident 18's Weights and Vital Report from 6/12/23 through…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-10-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on interview and record review it was determined the facility failed to monitor and maintain refrigerator and dishwasher temperatures for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for food borne illnesses. Findings include: Review of the facility's kitchen Equipment Temp Log on 10/8/24 for the refrigerator, freezer, dishwasher and dish rinse revealed the following: - The log included entries from 9/17/24 through 9/30/24. There was no record of temperatures taken prior to 9/17/24. - The log included entries from 10/1/24 through 10/4/24. On 10/5/24 the refrigerator and freezer temperature was documented but the dishwasher temperature was not documented. There were no documented temperatures after 10/5/24. On 10/8/24 at 8:18 AM Staff 7 (Dietary Manager) acknowledged the temperature logs were incomplete and not up to date.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-09 · tag F0761 — failed to label and store drugs safely — 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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 1 of 2s medication cart observed for secure medication carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: The facility's Storage of Medication Policy revised 4/2007 stated, The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. On 10/7/24 at 7:16 PM the medication cart near the nurses' station was unlocked and unattended by staff. On 10/7/24 at 7:18 PM Staff 9 (RN) confirmed the cart was left unlocked and unattended. On 10/9/24 at 10:07 AM Staff 2 (DNS) stated the medication cart was to be secured when unattended. 2. On 10/8/24 at 6:57 AM a bottle of Omeprazole (a stomach acid medication) was on the top of the medication cart near the nurses' station. The medication cart was unattended by staff. On 10/8/24 at 7:09 AM bubble-pack cards containing medications for Resident 6 were left on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-07-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to notify a physician and obtain orders for a worsening pressure ulcer for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. This placed resident at risk for worsening wounds. Findings include: Resident 6 was admitted to the facility in 12/2023 with diagnoses including dementia and peripheral vascular disease. A 12/30/23 admission Skin Observation Tool assessment revealed Resident 6 had a right heel Stage 1 (intact skin with non-blanchable redness) pressure ulcer which measured 0.1 cm x 0.1 cm. The resident's skin was warm, dry, and intact. Both heels were dry and scaly. A care plan initiated 1/2/24 revealed Resident 6 required one-person extensive assistance with repositioning in bed every two hours. The care plan had no information regarding Resident 6's risk of pressure ulcers or any interventions to address pressure ulcer risk. The admission MDS dated [DATE], with a review date of 1/6/24, revealed Resident 6 had severe…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-06-30 · tag F0727 — failed to provide required RN coverage — 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.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 16 of 30 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: Direct Care Daily Staff Reports indicated there was no RN coverage on the following dates: -9/2/22 -9/3/22 -9/4/22 -9/8/22 -9/9/22 -9/10/22 -9/11/22 -9/15/22 -9/16/22 -9/17/22 -9/18/22 -9/23/22 -9/24/22 -9/25/22 -9/29/22 -9/30/22 On 6/28/23 at 2:37 PM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) confirmed the dates with no RN coverage.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-06-30 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to ensure call lights were functioning for 1 of 1 facility and 2 of 3 sampled residents (#s 22 and 23). This placed residents at risk for delayed care and unmet needs. Findings include: On 6/28/23 at 10:28 AM Staff 4 (Regional Director of Operations) provided a call light replacement document that indicated the following: -On approximately 8/15/22 the facility call lights became non-functional; -Attempts were made to fix the call lights and were unsuccessful; -On 9/21/22 a quote was obtained for a replacement call light system and it was ordered; -The new call light system was installed on 9/27/22 [43 days later]; -During the time the call system was not working manual bells were provided to the residents and 15-minute checks were initiated. A review of the 15-minute call light log book from 8/25/22 through 9/23/22 (30 days) revealed the log was incomplete with no room numbers, names of residents or initials of staff who had completed the 15-minute checks. On 6/28/23 at 9:06 AM Staff 15 (CNA) stated in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Past Non-Compliance
• Potential for harm · E2023-06-30 · tag F0924 — pattern
  Put firmly secured handrails on each side of hallways.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and interview it was determined the facility failed to provide secured handrails in all corridors for 2 of 2 halls reviewed for environment. This placed residents at risk for accidents. Findings include: On 6/28/23 at 10:20 AM Resident 15 was observed using the handrail to self-propel from the living room common area to the [NAME] hall with the handrail loosely attached to the wall. On 6/28/23 at 12:52 PM Staff 21 (Maintenance Director) acknowledged multiple handrails were unsecured to the walls in the facility. On 6/28/23 at 12:56 PM Staff1 (Administrator) stated she was aware the handrails in the facility were unsecured to the walls throughout the facility.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-30 · tag F0584 — failed to keep a safe, clean, comfortable home — 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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview it was determined the facility failed to ensure resident equipment was maintained and sanitary for 2 of 3 sampled residents (#s 1, and 16) and flooring was safe in the living room reviewed for environment. This placed residents at risk for injury and unhomelike environment. Findings include: 1. On 6/26/23 at 1:06 PM Resident 16's wheelchair was observed to have a large amount of dry crusted food debris on the base of the wheelchair. On 6/29/23 at 3:37 PM Staff 2 (DNS) observed Resident 16's wheelchair and acknowledged it had dry crusted food debris at the base of the wheelchair. Resident 16 stated staff generally did not have time to clean it. Staff 2 stated night shift staff were to clean the wheelchairs. 2. On 6/26/23 at 2:06 PM Resident 1's wheelchair was observed to have dry crusted food on the base of the wheelchair. Resident 1 stated staff did not clean her/his wheelchair. On 6/29/23 at 3:36 PM Staff 2 (DNS) observed Resident 1's wheelchair and acknowledged it had dry crusted food debris at the base of the wheelchair. Staff 2 stated night…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming and nail care for 2 of 5 sampled residents (#s 3 and 8) reviewed for ADLs and hospice. This placed residents at risk for lack of grooming and hygiene. Findings included: 1. Resident 3 admitted to the facility in 3/2023 with diagnoses including chronic heart failure. A 4/4/23 Care Plan indicated Resident 3 was to have diabetic nail care by the night shift nursing staff and nails trimmed weekly. Resident 3 had an ADL care deficit related to stroke, was on hospice, required one or two staff for bathing and referred to the ADL care CNA task for bathing. The 5/2023 and 6/2023 TARs indicated weekly checks and nail care were completed by nursing staff. Resident 3 refused nail care on 5/17/23 and 5/31/23. The ADL care CNA task for bathing had no information regarding if Resident 3 was scheduled or received any type of bathing. A review of hospice notes revealed from 5/8/23 through 6/27/23 Resident 3 only received four bed baths by the hospice CNA…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure physician orders were followed and implemented for 3 of 5 sampled residents (#s 4, 12 and 23) reviewed for medications. This placed residents at risk for adverse side effects of medications. Findings include: 1. Resident 4 admitted to the facility on [DATE] with diagnoses including osteoporosis. a. The admission order dated 4/26/23 indicated Resident 4 was to receive alendronate (medication used to treat osteoporosis) 35 mg once weekly. Progress notes and 5/2023 MARs indicated alendronate was not administered as ordered on the following dates: -5/7/23 -5/14/23 -5/21/23 -5/28/23 The 6/2/23 Medication Report indicated Resident 4 missed four doses of alendronate. On 6/28/23 at 11:15 AM Staff 13 (RN) stated Resident 4 missed four weekly doses of alendronate due to a miscommunication and the nurse did not follow through with ordering medications. On 6/29/23 at 1:17 PM Staff 2 (DNS) acknowledged Resident 4 missed alendronate on the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-30 · tag F0691 — failed to provide colostomy / ostomy care — isolated
  Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to ensure physician orders were followed and implemented for 1 of 1 sampled resident (#21) reviewed for ostomy care. This placed residents at risk for skin breakdown. Findings include: Resident 21 readmitted to the facility in 1/2023 with diagnoses including malnutrition. The 3/1/23 physician order indicated the following: -Ileoostomy (a procedure in which part of the small bowel, is brought through the abdominal wall via a surgically-created opening called a stoma. The purpose of an ileostomy is to evacuate stool from the body via the ileum) care: change bag in the evening every three days and PRN leaking; -Cleanse skin with water only and allow to completely dry. The 3/17/23 8:14 PM Administration Note indicated there were no supplies to do proper change of the ostomy bag. The 3/18/23 at 8:20 PM Administration Note indicated proper supplies not available, replaced with similar situation. The 3/18/23 9:04 PM Administration Note indicated 0 supplies available that would work, had been changed 3 times in 3…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to KALESTA HEALTHCARE GROUP — 19 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OR