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Nursing home report card · Pendleton, OR

Willowbrook Post Acute

707 SW 37th Street, Pendleton, OR 97801

Call this home: (541) 276-3374

View this home on Medicare.gov ↗

Infection-control problems noted

Quick summary

Below-average Medicare rating

Overall rating is 1 of 5 stars. Its health-inspection rating is 1 of 5. Read the dated inspection findings and separate staffing and care ratings below.

Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.

How recent is this information?
Medicare file prepared
Aug 1, 2026
Our record last updated
Oct 15, 2026
Last routine health inspection
Aug 22, 2025

These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.

Medicare ratings

One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.

Overall rating
1out of 5

Combines inspection, staffing, and care measures.

Among the lowest Medicare ratings

Health inspections
1out of 5

Based on problems found during health inspections.

Among the lowest Medicare ratings

Nursing staff
4out of 5

Based on staffing levels and related measures.

Above average

Health and care results
3out of 5

Based on reported health and care results.

About average for U.S. nursing homes

What do the ratings and warnings mean?
Medicare ratings
One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
Inspection problems
Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
Abuse warning
Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
Nursing staff time
Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.

Learn about the records and their limits →

At a glance

These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.

Care and safety problems
43

Care, safety, and resident-rights issues on recent inspections

Fire-safety problems
0

Building, alarms, exits, and related safety citations

Reported fines
$80,796

Total fine amounts in the imported penalty records

Medicare file prepared
Aug 1, 2026

Medicare home ID: 385201

Inspection findings to read first

Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.

  • Immediate danger to residents · isolated case

    Dec 7, 2023 · Inspection rule 0600

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • Immediate danger to residents · isolated case

    Dec 7, 2023 · Inspection rule 0609

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • Immediate danger to residents · isolated case

    Dec 7, 2023 · Inspection rule 0658

    Ensure services provided by the nursing facility meet professional standards of quality.

Read the inspection history →

Nursing staff time

These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.

Registered nurses (RNs)
0.58hours per resident per day

about 35 minutes per resident per day

All nursing staff
5.03hours per resident per day

about 5 hr 2 min per resident per day

Registered nurse time on weekends
0.34hours per resident per day

about 20 minutes per resident per day

Latest inspection summary

A summary of the most recent routine inspections. You can open the dated findings below.

We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.

How this home compares

Compared with state and national averages. The numbers may cover different periods.

  • Overall CMS rating: 1 stars
  • Health inspection rating: 1 stars
  • Staffing rating: 4 stars
  • Registered nurse time per resident: 0.58 hours/day
  • Total nurse time per resident: 5.03 hours/day
See the dates used for these averages

Medicare file dates: this home Aug 1, 2026; Oregon averages Unavailable; U.S. averages Oct 1, 2026.

Other concerns in the records

These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.

  • Overall star rating is 2 or lower
  • Health inspection rating is 2 stars or lower
  • Recent citations include infection-control problems
  • Inspectors have listed an unusually high number of problems
  • CMS has fined this home in the recent reporting period

How serious were the problems?

Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.

  • Immediate danger to residents3 citations
  • Caused actual harm1 citation
  • Could have caused harm38 citations
  • Low risk of harm1 citation

Why inspectors showed up

Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.

Complaints
0
Routine
43
Fire safety
0
Other
0

Who owns it

Names CMS lists as owners or managers · reported as For profit - Limited Liability company.

  • We do not have individual owner names for this home.

Other homes in this group: All Pacs Group nursing homes

Inspection history

Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.

April 21, 20261 finding
  • Resident Rights problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0580 · code D

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

March 19, 20262 findings
  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0757 · code D

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0684 · code D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

August 22, 202515 findings
  • Pharmacy Service problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0761 · code E

    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.

  • Resident Rights problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0554 · code D

    Allow residents to self-administer drugs if determined clinically appropriate.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0600 · code D

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0602 · code D

    Protect each resident from the wrongful use of the resident's belongings or money.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0604 · code D

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0605 · code D

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0656 · code D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0689 · code D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0756 · code D

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0759 · code D

    Ensure medication error rates are not 5 percent or greater.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0825 · code D

    Provide or get specialized rehabilitative services as required for a resident.

  • Nursing and Physician Services problems
    Low risk of harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0732 · code B

    Post nurse staffing information every day.

  • Infection Control problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0880 · code D

    Provide and implement an infection prevention and control program.

  • Nutrition and Dietary problems
    Could have caused harm · widespread case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0812 · code F

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • Nursing and Physician Services problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0725 · code E

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

May 17, 202410 findings
  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0756 · code D

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • Quality of Life and Care problems
    Caused actual harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0688 · code G

    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.

  • Nutrition and Dietary problems
    Could have caused harm · widespread case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0812 · code F

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0656 · code D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0677 · code D

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0684 · code D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0689 · code D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0695 · code D

    Provide safe and appropriate respiratory care for a resident when needed.

  • Pharmacy Service problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0759 · code E

    Ensure medication error rates are not 5 percent or greater.

  • Pharmacy Service problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0758 · code D

    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…

December 7, 20236 findings
  • Administration problems
    Could have caused harm · widespread case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0868 · code F

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • Administration problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0835 · code E

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0600 · code J

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0609 · code J

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • Resident Assessment and Care Planning problems
    Immediate danger to residents · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0658 · code J

    Ensure services provided by the nursing facility meet professional standards of quality.

  • Freedom from Abuse, Neglect, and Exploitation problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0610 · code D

    Respond appropriately to all alleged violations.

December 13, 20199 findings
  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0656 · code D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0657 · code D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0686 · code D

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • Nutrition and Dietary problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0812 · code E

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • Nursing and Physician Services problems
    Could have caused harm · pattern case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0725 · code E

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • Quality of Life and Care problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0695 · code D

    Provide safe and appropriate respiratory care for a resident when needed.

  • Resident Rights problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0552 · code D

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0636 · code D

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  • Resident Assessment and Care Planning problems
    Could have caused harm · isolated case
    Inspection type and official rule codes

    Routine health inspection · CMS tag 0655 · code D

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Fines & penalties

These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.

  • Fine · May 17, 2024$61,458
  • Fine · Dec 7, 2023$19,338

Other homes in this chain

Pacs Group · other locations in Oregon

Related topics

Questions about Willowbrook Post Acute

What is Willowbrook Post Acute's Medicare star rating?
As of August 1, 2026, Willowbrook Post Acute in Pendleton, Oregon has an overall CMS rating of 1 out of 5 stars. Other CMS scores: health inspection 1 of 5, staffing 4 of 5, quality measures 3 of 5. These are CMS ratings based on inspection, staffing, and quality information, not consumer reviews.
Has Willowbrook Post Acute been fined?
As of August 1, 2026, the imported penalty records list $80,796 in reported fines for Willowbrook Post Acute. The individual penalty dates can differ from the Medicare file date; a listed fine does not establish that it was paid.
Does Willowbrook Post Acute have a Medicare abuse warning?
No. The current CMS Care Compare extract does not show an abuse warning icon for Willowbrook Post Acute in Pendleton, Oregon.
How does Willowbrook Post Acute compare with other nursing homes in Oregon?
Its overall CMS rating is 1 out of 5. A rating comparison is withheld because a matching source date or a usable rating is missing. Use the Oregon report card and dated inspection history for context; inspection totals alone are not a like-for-like performance comparison.

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