Willowbrook Post Acute
707 Sw 37th Street · Pendleton, OR · 97801 · 5412763374
59 certified beds For profit - Limited Liability company Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
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Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | 48% | median 45% |
| Fines (3-yr window) | 2 · $80,796 |
Inspection citations (43 in the current record)
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Potential for harm · D April 21, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected March 30, 2026 · Resident Rights
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Potential for harm · D March 19, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 6, 2026 · Quality of Life and Care
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Potential for harm · D March 19, 2026 · found via complaint
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected April 13, 2026 · Pharmacy Service
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Potential for harm · D August 22, 2025 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected November 21, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 22, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected September 29, 2025 · Resident Rights
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Potential for harm · D August 22, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected September 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 22, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected September 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 22, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 22, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · D August 22, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected September 29, 2025 · Pharmacy Service
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Potential for harm · D August 22, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected September 29, 2025 · Pharmacy Service
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Potential for harm · E August 22, 2025
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.
Corrected September 29, 2025 · Pharmacy Service
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Potential for harm · F August 22, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 29, 2025 · Nutrition and Dietary
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Potential for harm · D August 22, 2025
Provide and implement an infection prevention and control program.
Corrected September 29, 2025 · Infection Control
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Potential for harm · D August 22, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 22, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected September 29, 2025 · Nursing and Physician Services
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Potential for harm · D August 22, 2025 · found via complaint
Provide or get specialized rehabilitative services as required for a resident.
Corrected September 29, 2025 · Quality of Life and Care
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No harm found · B August 22, 2025
Post nurse staffing information every day.
Corrected September 29, 2025 · Nursing and Physician Services
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Actual harm · G May 17, 2024
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected June 20, 2024 · Quality of Life and Care
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Potential for harm · D May 17, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected June 20, 2024 · Quality of Life and Care
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Potential for harm · D May 17, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 20, 2024 · Quality of Life and Care
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Potential for harm · D May 17, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 20, 2024 · Quality of Life and Care
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Potential for harm · D May 17, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 20, 2024 · Quality of Life and Care
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Potential for harm · D May 17, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected June 20, 2024 · Pharmacy Service
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Potential for harm · D May 17, 2024
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.
Corrected June 20, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| May 17, 2024 | Fine | $61,458 |
| December 7, 2023 | Fine | $19,338 |
Better-scoring options nearby
No better-scoring facility within 25 miles in the current data. See the whole state.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385201 · certified since May 18, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.