Willowbrook Post Acute
707 Sw 37th Street, Pendleton, OR 97801
Willowbrook Post Acute is a nursing home in Pendleton, Oregon. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (541) 276-3374
- Last standard health inspection
- August 22, 2025 (1 year ago)
- Certified beds
- 59
- Residents per day, on average
- 55.7
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Willowbrook SNF Healthcare LLC
- Chain
- Pacs Group
- Takes part in
- Medicare and Medicaid
More health citations than the Oregon average (43 vs 34).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 5.0 to 4.3 hours per resident per day.
CMS update of October 8, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of May 27, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
1 citation
Health inspection on April 21, 2026
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on March 30, 2026.
CMS update of March 25, 2026
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
2 citations
Health inspection on March 19, 2026
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 6, 2026.
CMS has cited this home for F0684 2 times since 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 13, 2026.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of November 20, 2025
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of September 24, 2025
Star rating
The CMS staffing star rating changed from not rated by CMS to 4 of 5.
15 citations
Health inspection on August 22, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 29, 2025.
CMS has cited this home for F0812 3 times since 2019.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on September 29, 2025.
CMS has cited this home for F0725 2 times since 2019.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 29, 2025.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on September 29, 2025.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on September 29, 2025.
CMS has cited this home for F0600 2 times since 2023.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on November 21, 2024.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on September 29, 2025.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on September 29, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 29, 2025.
CMS has cited this home for F0656 3 times since 2019.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 29, 2025.
CMS has cited this home for F0689 2 times since 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on September 29, 2025.
CMS has cited this home for F0756 2 times since 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on September 29, 2025.
CMS has cited this home for F0759 2 times since 2024.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on September 29, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 29, 2025.
Citation F0732. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on September 29, 2025.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of June 25, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to not rated by CMS.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Name
CMS lists a new name for this home. It was WILLOWBROOK TERRACE.
10 citations
Health inspection on May 17, 2024
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
30 of 128 Oregon homes (23%) got a citation at the actual harm level in 2024.
Citation F0688. Severity G: actual harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 20, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 20, 2024.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 20, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 20, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 20, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 20, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 20, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on June 20, 2024.
CMS has cited this home for F0695 2 times since 2019.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on June 20, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 20, 2024.
2 citations
Fire safety inspection on May 17, 2024
CMS lists this as a standard inspection.
Citation K0341. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on June 20, 2024.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on June 20, 2024.
Fine
May 17, 2024 (2 years ago)
CMS fine of $61,458 on May 17, 2024.
CMS update of February 29, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 1 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
6 citations
Health inspection on December 7, 2023
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
13 of 128 Oregon homes (10%) got a citation at the immediate jeopardy level in 2023.
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 8, 2023.
Citation F0609. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 8, 2023.
Citation F0658. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on December 8, 2023.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on December 8, 2023.
Citation F0835. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on December 8, 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on December 8, 2023.
Fine
December 7, 2023 (2 years ago)
CMS fine of $19,338 on December 7, 2023.
9 citations
Health inspection on December 13, 2019
CMS lists this as a standard inspection.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on January 10, 2020.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 10, 2020.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on January 10, 2020.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on January 10, 2020.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on January 10, 2020.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 10, 2020.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on January 10, 2020.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on January 10, 2020.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on January 10, 2020.
2 citations
Fire safety inspection on December 13, 2019
CMS lists this as a standard inspection.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 10, 2020.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 10, 2020.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- APT, FREDERICKOperational/managerial control · not applicable · since 05/10/2024
- BAKER, NICHOLASOperational/managerial control · not applicable · since 09/19/2024
- JERGENSEN, JOSHUAOperational/managerial control · not applicable · since 05/10/2024
- MITCHELL, JOHNOperational/managerial control · not applicable · since 05/10/2024
- MORRIS, CHRISTOPHEROperational/managerial control · not applicable · since 09/01/2024
- TOWNSEND, DEBORAHOperational/managerial control · not applicable · since 02/17/2025
Questions
When was Willowbrook Post Acute last inspected?
CMS lists August 22, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Willowbrook Post Acute have?
CMS lists 43 health citations since December 13, 2019. CMS also calls these deficiencies.
Has Willowbrook Post Acute been fined?
CMS lists 2 fines in the past three years, $80,796 in total.
What is the CMS star rating of Willowbrook Post Acute?
Its CMS overall star rating is 1 of 5.
Is Willowbrook Post Acute a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.