Willowbrook Post Acute, Pendleton, Oregon
- 43
- Citations from health inspectionsOregon average: 34 a home
- 4
- Residents harmed or put in dangerOregon average: 1.5 a home
- $80,796
- Fines from the federal governmentOregon average: $27,522 a home
- 1 out of 5
- Overall rating in starsOregon average: 3.1
The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files
Six inspection visits produced 43 citations. Residents were in immediate danger in three findings. Residents were found hurt in one case. Federal fines came to $80,796 (two fines).
The CMS abuse icon is shown for this home. Care Compare adds it after a citation for abuse or neglect. Either a resident was harmed recently, or harm could have resulted over two inspections in a row.
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- The home's overall star rating
- 1 out of 5
- Rating for health inspections
- 1 out of 5
- Rating for staffing
- 4 out of 5
- Rating for quality of care
- 3 out of 5
- Nurse time for each resident
- 5.03 hours each dayThe Oregon average is 5.03 hours
- Time from registered nurses
- 0.58 hours each dayThe Oregon average is 0.72 hours
- Nursing staff who left during one year
- 52.9%against the Oregon average of 47.4%
- Beds that are certified
- 59
- Ownership
- Limited Liability company (for profit)
- Chain
- Pacs Group, with 275 homes
- Street address
- 707 Sw 37th Street, Pendleton, Oregon 97801
- County
- Umatilla
Each inspection's citations
Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.
One citation dated April 21, 2026
- F580 Telling the Family About a Change: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Two citations dated March 19, 2026
- F757 Unnecessary Drugs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F684 Quality of Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
15 citations dated Aug. 22, 2025
- F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents.
- F825 Specialized Rehabilitation Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
- F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
- F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, one or a few residents.
- F756 Monthly Drug Regimen Review: risk of harm, no one found hurt, one or a few residents.
- F732 Post Daily Nurse Staffing Information: minimal risk to residents, a pattern, several residents.
- F725 Enough Nursing Staff: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
- F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents.
- F605 Avoid Unnecessary Sedating or Psychiatric Drugs: risk of harm, no one found hurt, one or a few residents.
- F604 Freedom From Physical Restraints: risk of harm, no one found hurt, one or a few residents.
- F602 Protect Residents' Money and Belongings From Misuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F554 Let Residents Take Own Medicines When Appropriate: risk of harm, no one found hurt, one or a few residents.
10 citations dated May 17, 2024
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread.
- F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, a pattern, several residents.
- F758 Psychotropic Drugs and PRN Orders: risk of harm, no one found hurt, one or a few residents.
- F756 Monthly Drug Regimen Review: risk of harm, no one found hurt, one or a few residents.
- F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
- F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
- F688 Range of Motion and Mobility: residents were harmed, one or a few residents.
- F684 Quality of Care: risk of harm, no one found hurt, one or a few residents.
- F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents.
- F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
Six citations dated Dec. 7, 2023
- F868 Quality Group Membership and Quarterly Meetings: risk of harm, no one found hurt, widespread, found on a complaint visit.
- F835 Run the Facility Effectively: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
- F658 Care That Meets Professional Standards: immediate danger to residents, one or a few residents, found on a complaint visit.
- F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
- F609 Reporting Suspected Abuse: immediate danger to residents, one or a few residents, found on a complaint visit.
- F600 Freedom From Abuse and Neglect: immediate danger to residents, one or a few residents, found on a complaint visit.
Nine citations dated Dec. 13, 2019
- F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents.
- F725 Enough Nursing Staff: risk of harm, no one found hurt, a pattern, several residents.
- F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents.
- F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents.
- F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents.
- F656 A Complete Care Plan: risk of harm, no one found hurt, one or a few residents.
- F655 Baseline Care Plan at Admission: risk of harm, no one found hurt, one or a few residents.
- F636 Complete Assessments at Admission and Yearly: risk of harm, no one found hurt, one or a few residents.
- F552 Keep Residents Informed About Health and Care: risk of harm, no one found hurt, one or a few residents.
Payment Denials and Fines
| Date | Penalty | Amount |
|---|---|---|
| May 17, 2024 | Fine | $61,458 |
| Dec. 7, 2023 | Fine | $19,338 |
Ownership and Management of the Home
The CMS ownership file names no owner or operator for this home.
The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 385201. Other homes in Oregon.