Willow Creek Assisted Living

Last inspection

September 17, 2026

Inspections

7, 31 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

5

Regulatory actions

2

Fines assessed

$3,563.00 (7 violations)

Current owner since

April 1, 2026

License conditions and other regulatory actions

• August 19, 2026: License Condition, ALFCD26-00312; incident: CALMS - 00121110
  Based on preliminary information, obtained on or about August 19, 2026, during a licensure survey, ODHS concludes that Respondents acts or omissions create a situation where the residents of the facility and future residents are at risk of immediate jeopardy. Failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General)
• December 20, 2023 to February 14, 2024: License Condition, Failed to use an ABST ALFCD23-00763; incident: CALMS - 00050227
  The facility failed to ensure the Acuity-Based Staffing Tool (ABST) was reviewed before a resident moved into the facility, entries were reflective of the resident's current care needs, and the facility was staffing to the ABST generated staffing level.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• September 17, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 3, scope L3 Widespread
• August 20, 2026: Change of Owner, 9 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 4, scope L4 Pattern
  • C0160: Reasonable Precautions severity level 4, scope L4 Pattern
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0280: Resident Health Services severity level 2, scope L2 Isolated
  Show all 9

  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
• March 19, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• January 6, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
• October 17, 2023: Validation, 16 deficiencies cited report
  • C0000: Comment severity level 0
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected December 19, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected December 19, 2023
  Show all 17

  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated, corrected December 19, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected December 19, 2023
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected December 19, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected December 19, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected December 19, 2023
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected December 19, 2023
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected December 19, 2023
• August 17, 2023: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected December 30, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected December 30, 2023
• July 14, 2022: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 14, 2022

Substantiated abuse or neglect

• September 5, 2025: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility for their care. According to an investigation, on or about September 9, 2025, the facility received a call that AV was out of their prescribed pain medication, and it could not be refilled. Between September 5, 2025, and September 8, 2025, AV missed multiple doses of narcotic pain medication, resulting in pain over multiple days. A full audit of AV’s pain medications was conducted. The audit revealed discrepancies between the narcotic logbook and the electronic medication administration record. Narcotic logs show repeated extra doses administered outside scheduled times throughout July and August, far exceeding the prescribed schedule of one tablet every six hours. These unauthorized administrations occurred on numerous occasions, including multiple times per day during several weeks in August, causing AV’s medication supply to run out prematurely. Further review showed that Alleged Perpetrator 2 (AP2) was the only staff member documented as incorrectly administering the pain medication to AV. AP2 resigned unexpectedly on the same day this issue was discovered. Since the incident, there have been no further medication errors. AP2's actions are considered financial exploitation and constitutes abuse. The facility failed to provide appropriate services, relating to providing a safe medication administration system, administering medication as ordered, and keeping AV free from financial exploitation, which is a violation of resident rights, is neglect of care which constitutes abuse.

• August 25, 2025: Failed to provide service Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his/her care and has a history of cognitive decline despite only being in the facility for approximately one month. On or about August 25, 2025, AV was observed leaving the facility around 2:00 am. AV then walked to the middle of the street and to a nearby facility and started banging on the windows. Police found AV laying in the middle of the road and brought AV back to the facility. The facility failed to provide services, to include implementing interventions for AV's observed cognitive decline and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 12, 2025: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for care. W1 has a documented history of inappropriate behavior with other residents. On or about August 12, 2025, AV was inappropriately touched by W1, causing a loss of personal dignity and placing AV at risk for serious harm. The facility failed to provide services, to include properly care planning and/or implementing interventions to mitigate W1 known behaviors and ensure AV's safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 6, 2025: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility for care, to include medication administration. According to an investigation, AV was in the hospital after a heart attack and was discharged to the facility on July 31, 2025, with approximately 7 medications that were newly prescribed to AV, to include a blood thinner, a diuretic to decrease inflammation and edema, blood pressure medication, stomach ulcer medication, and a supplement for potassium. AV was not given these new medications until August 7, 2025, missing multiple doses, placing AV at risk for harm and repeated unreasonable discomfort. AV was then transported back to the hospital due to nausea, vomiting, leg edema, and unstable blood pressure and blood sugar. The facility failed to provide services, to include a safe medication administration system to ensure physician orders were followed and coordination of care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 1, 2023: Failed to assure resident rights Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) assure the Alleged Victim’s (AV) rights to receive items they purchased online. In June of 2023, the AV ordered a television online from Wal Mart to have delivered at the facility. Upon arrival of the television, the AP2 ordered staff to withhold the package until the AV paid their overdue rent. In September of 2023, AP2 was told by the local APS office they had to deliver the package to the AV as this was a violation of resident’s rights. On the same day, the AP2 delivered the package, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure resident rights which is a violation of Oregon Administrative Rules.

Substantiated licensing violations

• February 15, 2026: Failed to protect resident from financial exploitation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections)
  State’s findings

  The facility failed to protect the Alleged Victim (AV) from financial exploitation. According to an investigation, on or about February 15, 2026, AV's ring was missing from their apartment. The failure is a violation of Oregon Administrative Rules. The allegation that an unknown Alleged Perpetrator 2 (AP2) financially exploited AV was investigated and determined to be substantiated.

• January 1, 2023: Failed to report vaccination status Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about January 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from December 1, 2022 to December 31, 2022, for a total of 30 days.

• March 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about March 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from February 1, 2022 to February 28, 2022, for a total of 27 days.

• December 21, 2021: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility and Alleged Perpetrator #2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim (AV) received his/her proper medication. On or about December 21, 2021, AP2 gave AV medication that did not belong to AV. AV was sent to the emergency room for observation. AP2's actions placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.

• December 6, 2021: Failed to provide a safe medication administration system Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to ensure an adequate professional oversight of the medication administration system

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 48 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.