Willowbrook Post Acute
707 Sw 37th Street, Pendleton, OR 97801 · Umatilla County · (541) 276-3374
59 certified beds, about 53 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1989
CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
4 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385201 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on August 22, 2025, inspectors cited 14 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 43 health citations since December 2019, 4 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists 2 fines totaling $80,796 in the last three years; the largest was $61,458, and the latest is dated May 17, 2024.
Nurses and nurse aides worked 5.03 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.58 of those hours.
52.9% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to PACS Group, an affiliated group of 275 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
912/19
612/23
1005/24
1508/25
203/26
104/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
29D
6E
3F
Potential for minimal harm
0A
1B
0C
April 21, 2026Complaint inspection · 1 citation
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of the resident's transfer from the facility for 1 of 3 residents reviewed for change of condition (#3). This placed residents and residents' representatives at risk for not being able to contact each other.
March 19, 2026Complaint inspection · 2 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident did not self-administer non-prescribed medications for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk for incorrect medication administration.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure the resident was adequately monitored, had an adequate indication for use, and physician orders for medications for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk for adverse medication side effects of unnecessary medications.
August 22, 2025Standard inspection, Complaint inspection · 15 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to store and handle food in a sanitary manner in 1 of 1 kitchen and 2 of 2 snack refrigerators. This placed residents at risk for food borne illness.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of ADL care needs.
- 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper storage temperatures were logged and maintained for 1 of 1 medication refrigerator reviewed for medication storage. This placed residents at risk for degradation and reduced efficacy of biologicals and medication.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 3 of 3 sampled residents (#'s 31, 35 and 46) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration and adverse medication side effects.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse by another resident for 1 of 7 sampled residents (#17) reviewed for abuse. This placed residents at risk for abuse.
- D Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were appropriately assessed for the use of a physical restraint for 1 of 1 sampled resident (#30) reviewed for restraints. This placed residents at risk for restricted freedom of movement and a decline in physical functioning.
- D Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review the facility failed to ensure a clinical rational for administering a psychotropic medication for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at increased risk for adverse consequence of antipsychotic medication.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a person-centered care plan related to ostomy care for 1 of 1 sampled resident (#30) reviewed for bowel and bladder. This placed residents at risk for infections and lack of ADL care.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to prevent an avoidable fall for 1 of 4 sampled residents (#3) reviewed for falls. This placed residents at risk for injury.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#9) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medications.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were eight errors out of 30 opportunities resulting in a 26.67 percent error rate. This placed residents at risk for adverse medication side effects and pain.
- D Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide physical, occupational and speech therapy services as ordered for 3 of 3 sampled residents (#s 3, 26 and 60) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure enhanced barrier precautions were implemented for 1 of 3 sampled residents (#9) reviewed for infection control. This placed residents at risk for transmission of infection.
- B Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate and complete for 13 of 77 days reviewed for staffing. This placed residents and the public at risk for inaccurate staffing information.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of resident property for 1 of 1 sampled resident (#26) reviewed for misappropriation of controlled pain medication. This placed residents at risk for unmanaged pain.
May 17, 2024Standard inspection, Complaint inspection · 10 citations
- 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.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to prevent loss of range of motion and development of contractures for 1 of 1 sampled resident (#23) reviewed for contractures. This failure resulted in Resident 23 developing bilateral (both) hand contractures and experiencing significant pain in her/his hands.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage and cross contamination, failed to maintain a clean and sanitary environment for food preparation and failed to prevent potential contamination of the ice machine in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens.
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were seven errors out of 28 opportunities resulting in a 25 percent error rate. This placed residents at risk for adverse medication side effects and pain.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review the facility failed to implement the plan of care for 2 of 6 sampled residents (#s 32 and 139) who were reviewed for ADLs. This placed residents at risk for unmet needs and injury.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide the necessary care and services to maintain personal hygiene for 1 of 6 sampled residents (#15) reviewed for ADLs. This placed residents at risk for poor personal hygiene.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to monitor skin conditions for 1 of 1 sampled resident (#28) reviewed for skin conditions. This placed residents at risk for unmet care needs.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement fall prevention interventions and evaluate and analyze resident falls for 2 of 5 sampled residents (#s 23 and 32) reviewed for position and mobility and accidents. This placed residents at risk for injury.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to obtain physician orders, ensure respiratory equipment was properly maintained and administer oxygen as ordered for 2 of 3 sampled residents (#s 28 and 32) reviewed for respiratory care. This placed residents at risk for adverse respiratory effects and discomfort.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to document a clinical rationale for pharmacy recommendations for 2 of 5 sampled residents (#s 3 and 24) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration.
- 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 limited.
Inspectors wroteBased on interview and record review it was determined the facility failed to attempt gradual dose reductions (GDRs) for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for unnecessary psychotropic medications.
December 7, 2023Complaint inspection · 6 citations
- J Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from mental, verbal and physical abuse and intimidation for 3 of 3 residents (#s 1, 2 and 3) reviewed for abuse. This failure resulted in Resident 2's right to refuse care not being honored, resulting in mental anguish as evidenced by physically forcing care upon and mocking Resident 2. Additionally, this placed all residents at risk for abuse and intimidation.
- J Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report allegations of abuse for 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for abuse. This failure to report past abuse allegations resulted in Resident 2's physical, verbal and mental abuse and placed all residents at increased risk of abuse and intimidation.
- J Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined Staff 3 (RN) failed to provide care and services which allowed residents the right to refuse care and physically forced personal care upon 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for abuse and nine unsampled residents, which did not meet professional standards of quality. This failure resulted in widespread refusal of care not being honored by Staff 3, provision of care against residents' wishes, mental anguish due to intimidation, mocking of Resident 2, potential of further vilation of resident rights, and care being forced upon all residents.
- F Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review it was determined the Medical Director did not have meaningful participation in the QAPI (Quality Assessment and Performance Improvement) program for 1 of 1 QAPI team reviewed for QAPI. This placed residents at risk for lack of Medical Director oversight of all resident care policies in the facility.
- E Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interview and record review it was determined Staff 1 (Administrator) failed to implement written policies and prevent further incidents of staff abuse of residents when repeatedly notified of concerns for 2 of 2 sampled residents reviewed for abuse and nine unsampled residents. The repeated failure to investigate allegations of abuse resulted in residents being exposed to mental, physical and verbal abuse and manipulation which placed the residents at risk for a decline in their overall physical, mental and psychological well-being.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate allegations of abuse for 2 of 3 sampled residents (#s 1 and 2) reviewed for abuse. This placed residents at risk for increased risk of physical, mental and verbal abuse.
December 13, 2019Standard inspection · 9 citations
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure call lights were answered timely on 3 of 3 halls reviewed for call light response time. This placed residents at risk for unmet needs.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined the facility failed to provide a clean and sanitary environment for 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for unsanitary food preparation surfaces.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain informed consent prior to initiating therapy with antipsychotic medication for 1 of 5 residents reviewed for psychotropic medication (#11). This placed residents or their representatives at risk of making uninformed decisions.
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure timely completion of MDS assessments for 2 of 7 sampled residents (#s 29 and 143) reviewed for medication and nutrition. This placed residents at risk for unassessed needs. Findings Include: The MDS 3.0 RAI Manual stated: The MDS completion date (Item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than. The CAA(s) completion date (Item V0200B2) must be no later than day 14. 1. Resident 143 was admitted to the facility on [DATE]. On 12/12/19 Resident 143's admission MDS dated [DATE] was incomplete. The admission MDS was signed 12/10/19, 22 days after admission. CAAs were incomplete and not signed, 24 days after admission. On 12/12/19 at 2:09 PM Staff 8 (RCM) confirmed Resident 140's admission MDS was incomplete. 2. [...]
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a resident centered baseline care plan for 1 of 3 sampled residents (#140) reviewed for accidents. This placed residents at risk for unmet needs.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement a comprehensive care plan related to falls for 2 of 3 sampled residents (#s 13 and 140) reviewed for accidents and hydration. This placed residents at risk for unmet needs.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review it was determined the facility failed to revise a resident's plan of care with preventative measures related to new onset pressure injury for 1 of 2 residents (#11) reviewed for pressure ulcers. This placed residents at risk for delayed treatment and healing.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to promptly determine a cause and develop new interventions to address a pressure related skin injury and failed to follow the plan of care with documented evidence of weekly skin checks for 1 of 2 sampled residents (#11) reviewed for pressure ulcers. This placed residents at risk for further injury and delayed healing.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the resident's record reflected ongoing assessment of the resident's respiratory status, response to oxygen therapy, and the attending practitioner's orders and indication for use of supplemental oxygen for 1 of 2 sampled residents (#140) reviewed for respiratory care. This placed residents at risk for respiratory distress.
Fire safety inspections
4 fire safety citations on file: 2 on May 17, 2024, 2 on December 13, 2019.
Every fire safety citation4 citations
- D Install a fire alarm system that can be heard throughout the facility.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Inspect, test, and maintain automatic sprinkler systems.
- E Ensure proper usage of power strips and extension cords.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| May 17, 2024 | Fine | $61,458 |
| December 7, 2023 | Fine | $19,338 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.03 | 5.03 | 3.86 |
| Registered nurses | 0.58 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.59 | 4.51 | 3.42 |
| Nurse aides | 3.68 | ||
| Licensed practical nurses | 0.77 | ||
| Nursing staff turnover (share who left in a year) | 52.9% | 47.4% | 45.8% |
| Registered nurse turnover | 54.5% | 51.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.64 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.21 on weekdays and 4.59 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 18.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.49 in April to June 2025 to 5.03 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.03 | 0.58 | 5.21 | 4.59 | 18.4% | 0 of 90 | 53 |
| Oct to Dec 2025 | 4.17 | 0.76 | 4.46 | 3.42 | 8.6% | 0 of 92 | 53 |
| Jul to Sep 2025 | 4.28 | 0.89 | 4.51 | 3.71 | 18.6% | 0 of 92 | 51 |
| Apr to Jun 2025 | 4.49 | 1.00 | 4.74 | 3.86 | 22.5% | 0 of 91 | 48 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 21.6 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.5 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.2 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 24.2 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.0 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 29.4 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.9 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 24.0 | 16.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 5.8 | 2.4 | 1.8 |
Owners and operators
Legal business name: WILLOWBROOK SNF HEALTHCARE LLC. CMS links this home to PACS Group, a group of 275 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Truist Bank | 5% or greater security interest | Organization | 09/01/2024 | |
| Apt, Frederick | Operational/managerial control | Individual | 05/10/2024 | |
| Baker, Nicholas | Operational/managerial control | Individual | 09/19/2024 | |
| Jergensen, Joshua | Operational/managerial control | Individual | 05/10/2024 | |
| Mitchell, John | Operational/managerial control | Individual | 05/10/2024 | |
| Morris, Christopher | Operational/managerial control | Individual | 09/01/2024 | |
| Townsend, Deborah | Operational/managerial control | Individual | 02/17/2025 | |
| Deh Enterprises LLC | Adp of the SNF | Organization | 09/01/2024 | |
| Providence Administrative Consulting Services Inc | Adp of the SNF | Organization | 09/01/2024 | |
| Baker, Nicholas | Adp of the SNF | Individual | 01/23/2026 | |
| Morris, Christopher | Adp of the SNF | Individual | 01/23/2026 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 10 problems in this area, most recently on March 19, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 7 problems in this area, most recently on March 19, 2026: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 7 problems in this area, most recently on August 22, 2025: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
- When is the care plan meeting, and can family attend it?Inspectors cited 7 problems in this area, most recently on August 22, 2025: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Willowbrook Post Acute's Medicare star rating?
- CMS rates Willowbrook Post Acute 1 out of 5 stars overall, with 1 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Willowbrook Post Acute get at its last inspection?
- 14 health deficiencies at the standard inspection on August 22, 2025. The Oregon average is 9.2.
- Has Willowbrook Post Acute been fined?
- Yes. CMS lists 2 fines totaling $80,796 in the last three years.
- Does Willowbrook Post Acute accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Willowbrook Post Acute?
- CMS lists 11 owners and managers, and links the home to PACS Group. Legal business name: WILLOWBROOK SNF HEALTHCARE LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.