Willow Creek Memory Care

Last inspection

September 17, 2026

Inspections

7, 44 deficiencies cited

Substantiated abuse

8

Substantiated licensing violations

3

Regulatory actions

2

Fines assessed

$2,125.00 (6 violations)

Current owner since

April 1, 2026

License conditions and other regulatory actions

• August 19, 2026: License Condition, RCFCD26-00736; incident: CALMS - 00121108
  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)
• July 31, 2025 to October 6, 2025: License Condition, Failed to provide safe environment RCFCD25-00875; incident: CALMS - 00084601
  Based on preliminary information, 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); 411-054-0027 (Resident Rights and Protections); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)

Inspections

• September 17, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 3, scope L3 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• August 20, 2026: Change of Owner, 12 deficiencies cited report
  • C0160: Reasonable Precautions severity level 4, scope L4 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
  • C0300: Systems: Medications and Treatments severity level 4, scope L4 Pattern
  • C0303: Systems: Treatment Orders severity level 4, scope L4 Pattern
  Show all 12

  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • Z0140: Administration Responsibilities severity level 4, scope L4 Pattern
  • Z0142: Administration Compliance severity level 4, scope L4 Pattern
  • Z0162: Compliance with Rules Health Care severity level 4, scope L4 Pattern
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern
• March 19, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• January 6, 2025: Kitchen, 3 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• October 9, 2023: Validation, 21 deficiencies cited report
  • C0000: Comment severity level 0
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected December 30, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected December 30, 2023
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected December 30, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected December 30, 2023
  Show all 23

  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected December 30, 2023
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected December 30, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected December 30, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected March 15, 2024
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected December 30, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected December 30, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected March 15, 2024
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected December 30, 2023
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected December 30, 2023
  • C0540: Heating and Ventilation severity level 2, scope L2 Widespread, corrected December 30, 2023
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread, corrected December 30, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected March 15, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected March 15, 2024
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected December 30, 2023
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected December 30, 2023
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected December 30, 2023
  • Z0165: Behavior severity level 2, scope L2 Pattern, corrected December 30, 2023
  • Z0176: Resident Rooms severity level 2, scope L2 Widespread, corrected December 30, 2023
• August 17, 2023: State Licensure, 2 deficiencies 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected December 30, 2023
• July 14, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 14, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 14, 2022

Substantiated abuse or neglect

• March 13, 2026: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his or her care and medication management. On or about March 13, 2026, AV was released from the hospital with an antibiotic prescription. According to an investigation, the medication was received by the facility, but was not given to AV until approximately March 16, 2026, placing AV at risk for worsening infection. The facility failed to provide a safe medication administration system, which is a violation of resident rights is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(ii).

• March 6, 2026: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility for their care, including medication management. According to an investigation, on or about March 5, 2026, AV was tested for a UTI and an antibiotic was ordered the next day. AV did not start their antibiotic medication until approximately March 11, 2026, as it could not be located, posing a risk of harm. AV was also seen to be “out of it” and “not aware” and noted to be in pain. The facility failed to provide a safe medication administration system and failed to ensure medication was administered as ordered, which is a violation of resident rights, is neglect of care which constitutes abuse.

• April 12, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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) relied on the facility for care and assistance with their medications. AV is prescribed a medicated pain patch, and every 72 hours staff are required to take off the old patch when a new one is placed. On or about April 12, 2025, AV was found with two (2) pain patches on their skin. According to an investigation, this was the second time the AV was found with two patches on at the same time and AV appeared more tired than usual. The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered, which is considered neglect of care and constitutes abuse.

• May 26, 2024: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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, which includes medication administration. On or about May 26, 2024, AV was only given a partial dose of their insulin that controls blood sugar, due to the facility running out. The facility took multiple days to get AV's insulin refilled, due to it being a holiday. AV had higher CBG levels during the days they missed the insulin dosage but did not show symptoms of hyperglycemia or hypoglycemia. While waiting for the insulin to be refilled, the Alleged Perpetrator 2 (AP2) gave AV a different type of blood sugar medication, in error. An investigation determined no abuse occurred by the Alleged Perpetrator 2 (AP2). The facility failed to provide services to AV, to include a safe medication system to ensure medications were available and to ensure physician orders were followed, placing AV at risk for harm, which is a violation of resident’s rights is neglect of care and constitutes abuse.

• December 20, 2023: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to care plan appropriate interventions for Witness 1’s (W1) history of resident to resident altercations. On or about December 20, 2023, W1 grabbed the Alleged Victim’s (AV) chest inappropriately. From approximately October 21, 2023, through December 20, 2023, there have been a total of five (5) altercations between W1 and the AV. There are no documented interventions in either service plan and no temporary service plans were put into effect, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• May 25, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, the facility's failure to update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required.

• May 25, 2026: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  Based on interview and record review, conducted during a site visit on 06/11/26, the facility's failure to have a service plan that reflects the resident's needs as identified in the evaluation and to ensure the implementation of services. The facility’s failure is a violation of Oregon Administrative Rules.

• May 15, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, the facility failed to update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

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 16 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.