Nursing homes › Oregon › Willowbrook Post Acute
707 Sw 37Th Street, Pendleton, OR 97801 · 5412763374 · 59 certified beds
Per CMS filings, this facility is affiliated with Pacs Group, a group operating 281 facilities in 16 states. Group record: average rating 2.8/5, 26 abuse citation icons, 13 facilities on the Special Focus list, $8,841,332 in federal fines. This facility rates below its group average (2.8/5).
All-time on record: 43 deficiency citations, including 3 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-04-21 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | complaint | corrected 2026-03-30 |
| 2026-03-19 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2026-04-06 |
| 2026-03-19 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | complaint | corrected 2026-04-13 |
| 2025-08-22 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Health | corrected 2025-09-29 |
| 2025-08-22 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | complaint | corrected 2025-09-29 |
| 2025-08-22 | 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. | E | Health | corrected 2025-09-29 |
| 2025-08-22 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2025-09-29 |
| 2025-08-22 | Protect each resident from the wrongful use of the resident's belongings or money. | D | complaint | corrected 2024-11-21 |
| 2025-08-22 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Ensure medication error rates are not 5 percent or greater. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Provide or get specialized rehabilitative services as required for a resident. | D | complaint | corrected 2025-09-29 |
| 2025-08-22 | Provide and implement an infection prevention and control program. | D | Health | corrected 2025-09-29 |
| 2025-08-22 | Post nurse staffing information every day. | B | Health | corrected 2025-09-29 |
| 2024-05-17 | 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. | G | Health | corrected 2024-06-20 |
| 2024-05-17 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Health | corrected 2024-06-20 |
| 2024-05-17 | Ensure medication error rates are not 5 percent or greater. | E | Health | corrected 2024-06-20 |
| 2024-05-17 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | complaint | corrected 2024-06-20 |
| 2024-05-17 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Health | corrected 2024-06-20 |
| 2024-05-17 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2024-06-20 |
| 2024-05-17 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2024-06-20 |
| 2024-05-17 | Provide safe and appropriate respiratory care for a resident when needed. | D | Health | corrected 2024-06-20 |
| 2024-05-17 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Health | corrected 2024-06-20 |
| 2024-05-17 | 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. | D | Health | corrected 2024-06-20 |
| 2023-12-07 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | complaint | corrected 2023-12-08 |
| 2023-12-07 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | J | complaint | corrected 2023-12-08 |
| 2023-12-07 | Ensure services provided by the nursing facility meet professional standards of quality. | J | complaint | corrected 2023-12-08 |
| 2023-12-07 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F | complaint | corrected 2023-12-08 |
| 2023-12-07 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | E | complaint | corrected 2023-12-08 |
| 2023-12-07 | Respond appropriately to all alleged violations. | D | complaint | corrected 2023-12-08 |
| Date | Type | Amount |
|---|---|---|
| 2024-05-17 | Fine | $61,458 |
| 2023-12-07 | Fine | $19,338 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| APT, FREDERICK | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/10/2024 |
| BAKER, NICHOLAS | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/19/2024 |
| JERGENSEN, JOSHUA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/10/2024 |
| MITCHELL, JOHN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/10/2024 |
| MORRIS, CHRISTOPHER | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/01/2024 |
| TOWNSEND, DEBORAH | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/17/2025 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 385201. Corrections: data@carerecords.org.