Starfile / Oregon

WILLOWBROOK POST ACUTE

707 SW 37TH STREET, PENDLETON, OR 97801 · CCN 385201

Inspection history vs Oregon & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$80,796

Number of fines

2

Number of penalties

2

Payment denials

0

Chain

Chain

PACS GROUP

Facilities in chain

264

Chain avg overall

2.90 / 5

Inspection citations (40)3 immediate jeopardy1 actual harm

1. DF0554Allow residents to self-administer drugs if determined clinically appropriate.2025-08-22 · Health · corrected 2025-09-29

   Potential for more than minimal harm

2. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-08-22 · Health · corrected 2025-09-29

   Potential for more than minimal harm

3. DF0602Protect each resident from the wrongful use of the resident's belongings or money.2025-08-22 · Health · corrected 2024-11-21

   Potential for more than minimal harm

4. DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2025-08-22 · Health · corrected 2025-09-29

   Potential for more than minimal harm

5. DF0605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.2025-08-22 · Health · corrected 2025-09-29

   Potential for more than minimal harm

6. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-08-22 · Health · corrected 2025-09-29

   Potential for more than minimal harm

7. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-08-22 · Health · corrected 2025-09-29

   Potential for more than minimal harm

8. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-08-22 · Health · corrected 2025-09-29

   Potential for more than minimal harm

9. BF0732Post nurse staffing information every day.2025-08-22 · Health · corrected 2025-09-29

   Potential for minimal harm

10. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-08-22 · Health · corrected 2025-09-29

    Potential for more than minimal harm

11. DF0759Ensure medication error rates are not 5 percent or greater.2025-08-22 · Health · corrected 2025-09-29

    Potential for more than minimal harm

12. EF0761Ensure 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.2025-08-22 · Health · corrected 2025-09-29

    Potential for more than minimal harm

13. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-08-22 · Health · corrected 2025-09-29

    Potential for more than minimal harm

14. DF0825Provide or get specialized rehabilitative services as required for a resident.2025-08-22 · Health · corrected 2025-09-29

    Potential for more than minimal harm

15. DF0880Provide and implement an infection prevention and control program.2025-08-22 · Health · corrected 2025-09-29

    Potential for more than minimal harm

16. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

17. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

18. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

19. GF0688Provide 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.2024-05-17 · Health · corrected 2024-06-20

    Actual harm

20. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

21. DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

22. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

23. DF0758Implement 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.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

24. EF0759Ensure medication error rates are not 5 percent or greater.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

25. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-05-17 · Health · corrected 2024-06-20

    Potential for more than minimal harm

26. JF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-12-07 · Health · corrected 2023-12-08

    Immediate jeopardy

27. JF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-12-07 · Health · corrected 2023-12-08

    Immediate jeopardy

28. DF0610Respond appropriately to all alleged violations.2023-12-07 · Health · corrected 2023-12-08

    Potential for more than minimal harm

29. JF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-12-07 · Health · corrected 2023-12-08

    Immediate jeopardy

30. EF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2023-12-07 · Health · corrected 2023-12-08

    Potential for more than minimal harm

31. FF0868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly2023-12-07 · Health · corrected 2023-12-08

    Potential for more than minimal harm

32. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

33. DF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

34. DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

35. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

36. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

37. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

38. DF0695Provide safe and appropriate respiratory care for a resident when needed.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

39. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

40. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2019-12-13 · Health · corrected 2020-01-10

    Potential for more than minimal harm

Ownership

Other facilities in PENDLETON

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.