Willowbrook Post Acute — nursing home in Pendleton, OR

Facility type: Nursing home · SNF / NF
CMS provider type: Medicare and Medicaid
Certified beds: 59 CMS-certified beds (not state-licensed beds)
Licensed beds: State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead.
Average residents per day: 55.7 CMS, MDS-derived
CMS Certification Number: 385201
Certification status: Active CMS certification Verified
First approved (Medicare/Medicaid): May 18, 1989
Ownership type: For profit - Limited Liability company
Operator (legal business name): Willowbrook SNF Healthcare LLC
CMS chain: Pacs Group 277 facilities
Phone: (541) 276-3374
Resident & family council: Resident
Sprinklers in all required areas: Yes
Official profile: Medicare Care Compare ↗

Inspection record · CMS window

Verified

Inspections

9

latest Apr 21, 2026

Citations

47

43 health · 4 fire

Harm or worse

4

3 immediate jeopardy

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J3	K·	L·
Actual harm	G1	H·	I·
Potential harm	D31	E8	F3
Minimal	A·	B1	C·

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

CMS Five-Star ratings

Federal · CMS

Overall

Health inspections

Staffing

Quality measures

Penalties · about the last 3 years

Fines

2

$80,796

Payment denials

0

Latest

May 17, 2024

Federal certification

Federal · CMS

Authority: Centers for Medicare & Medicaid Services (CMS), surveyed by the state survey agency
CCN: 385201
Program: Medicare and Medicaid
Medicare (SNF): Certified
Medicaid (NF): Certified
Certified beds: 59
First approved: May 18, 1989
Located in a hospital: No
Status: Active CMS certification as of CMS release Oct 1, 2026
Evidence: Verified

State license

State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead. State coverage for Oregon.

Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

Date	Domain	Survey types	Citations	Most severe	Open
Apr 21, 2026	Health	Health Complaint	1	Potential harm	—	Open →
Mar 19, 2026	Health	Health Complaint	2	Potential harm	—	Open →
Aug 22, 2025	Fire safety	Fire Safety Standard	0	No citations	—	Open →
Aug 22, 2025	Health	Health Complaint, Health Standard	15	Potential harm	—	Open →
May 17, 2024	Fire safety	Fire Safety Standard	2	Potential harm	—	Open →
May 17, 2024	Health	Health Complaint, Health Standard	10	Actual harm	—	Open →
Dec 7, 2023	Health	Health Complaint	6	Immediate jeopardy	—	Open →
Dec 13, 2019	Fire safety	Fire Safety Standard	2	Potential harm	—	Open →
Dec 13, 2019	Health	Health Standard	9	Potential harm	—	Open →

Enforcement

Penalties

Civil money penalties and denials of payment for new admissions, as published by CMS (about the last three years). Amounts may change on appeal.

Date	Type	Amount	Payment denial	Record
May 17, 2024	Civil money penalty (fine)	$61,458	—	385201\|Fine\|46431
Dec 7, 2023	Civil money penalty (fine)	$19,338	—	385201\|Fine\|46357

Scope × severity

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J3	K·	L·
Actual harm	G1	H·	I·
Potential harm	D31	E8	F3
Minimal	A·	B1	C·

By concept

Date	Tag	Deficiency	Scope / severity	Correction	Flags
Apr 21, 2026	F-0580	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Past non-compliance Mar 30, 2026	Complaint
Mar 19, 2026	F-0684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Apr 6, 2026	Complaint
Mar 19, 2026	F-0757	Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Apr 13, 2026	Complaint
Aug 22, 2025	F-0554	Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0600	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 Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Sep 29, 2025	Complaint
Aug 22, 2025	F-0602	Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Past non-compliance Nov 21, 2024	Complaint
Aug 22, 2025	F-0604	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0605	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0656	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 Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0725	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision	E · Potential harm Pattern	Corrected Sep 29, 2025	Complaint
Aug 22, 2025	F-0756	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 Deficiencies · Medication management	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0761	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. Pharmacy Service Deficiencies · Medication management	E · Potential harm Pattern	Corrected Sep 29, 2025
Aug 22, 2025	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	F · Potential harm Widespread	Corrected Sep 29, 2025
Aug 22, 2025	F-0825	Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Sep 29, 2025	Complaint
Aug 22, 2025	F-0880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention	D · Potential harm Isolated	Corrected Sep 29, 2025
Aug 22, 2025	F-0732	Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision	B · Minimal Pattern	Corrected Sep 29, 2025
May 17, 2024	F-0688	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. Quality of Life and Care Deficiencies · Clinical care	G · Actual harm Isolated	Corrected Jun 20, 2024
May 17, 2024	K-0341	Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	F-0656	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 Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 20, 2024	Complaint
May 17, 2024	F-0677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	F-0684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	F-0689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	F-0695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	F-0756	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 Deficiencies · Medication management	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	F-0758	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. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Jun 20, 2024
May 17, 2024	F-0759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management	E · Potential harm Pattern	Corrected Jun 20, 2024
May 17, 2024	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	F · Potential harm Widespread	Corrected Jun 20, 2024
Dec 7, 2023	F-0600	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 Deficiencies · Resident rights & abuse/neglect	J · Immediate jeopardy Isolated	Corrected Dec 8, 2023	Complaint
Dec 7, 2023	F-0609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	J · Immediate jeopardy Isolated	Corrected Dec 8, 2023	Complaint
Dec 7, 2023	F-0658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care	J · Immediate jeopardy Isolated	Corrected Dec 8, 2023	Complaint
Dec 7, 2023	F-0610	Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Dec 8, 2023	Complaint
Dec 7, 2023	F-0835	Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records	E · Potential harm Pattern	Corrected Dec 8, 2023	Complaint
Dec 7, 2023	F-0868	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records	F · Potential harm Widespread	Corrected Dec 8, 2023	Complaint
Dec 13, 2019	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 10, 2020
Dec 13, 2019	K-0920	Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 10, 2020
Dec 13, 2019	F-0552	Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jan 10, 2020
Dec 13, 2019	F-0636	Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 10, 2020
Dec 13, 2019	F-0655	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 10, 2020
Dec 13, 2019	F-0656	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 Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 10, 2020
Dec 13, 2019	F-0657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 10, 2020
Dec 13, 2019	F-0686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 10, 2020
Dec 13, 2019	F-0695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 10, 2020
Dec 13, 2019	F-0725	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision	E · Potential harm Pattern	Corrected Jan 10, 2020
Dec 13, 2019	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	E · Potential harm Pattern	Corrected Jan 10, 2020

“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.

Five-Star ratings

Federal · CMS

Overallstate 3.2

Health inspectionsstate 2.8

Staffingstate 3.9

Quality measuresstate 3.7

Long-stay QM

Short-stay QM

CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.

Nurse staffing · hours per resident per day

Total nurse staffing4.34

State avg 5.13US avg 3.90

Registered nurse (RN)0.46

State avg 0.76US avg 0.69

Licensed practical nurse0.66

State avg 0.89US avg 0.86

Nurse aide3.22

State avg 3.48US avg 2.35

Weekend total nurse3.80

State avg 4.56US avg 3.43

Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.50 (case-mix index 1.35).

Staff turnover

Total nursing staff turnover55.1%

State avg 43.5%US avg 45.3%

Registered nurse turnover83.3%

State avg 49.5%US avg 42.5%

Administrators who left1

State avg 1US avg 1

Health survey score

Cycle 1 standard survey: Aug 22, 2025
Cycle 1 health score: 84
Total weighted score: 139

Operating entity

Willowbrook SNF Healthcare LLC

CMS legal business name of the certified provider. Operates this facility only.

VerifiedLinked by exact legal name

CMS chain

Pacs Group

277 facilities in 16 states. CMS chain ID 690.

VerifiedAssigned by CMS

Chain average overall rating (CMS): 3

Ownership disclosures

Disclosures

11

Organizations

3

Individuals

8

CMS Ownership file

All disclosed roles

Operator, owners, managers, officers and lenders are distinct roles and are never flattened into one entity. Organizations link across facilities by exact normalized legal name; individuals are listed per facility only.

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Frederick Apt	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	May 10, 2024
Nicholas Baker	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Sep 19, 2024
Joshua Jergensen	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	May 10, 2024
John Mitchell	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	May 10, 2024
Christopher Morris	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Sep 1, 2024
Deborah Townsend	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Feb 17, 2025
Truist Bank	Organization	Mortgage / security interest	5% OR GREATER SECURITY INTEREST	not provided	Sep 1, 2024
Deh Enterprises LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Sep 1, 2024
Providence Administrative Consulting Services Inc	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Sep 1, 2024
Nicholas Baker	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jan 23, 2026
Christopher Morris	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jan 23, 2026

Same chain in Oregon

All 276 in chain →

Facility	Beds	Last inspection	Citations (window)	Fines
Menlo Park Post Acute 745 NE 122nd Avenue, Portland, OR 97230 CCN 385044	83	May 22, 2026	48	—
Porthaven Post Acute 5330 NE Prescott Street, Portland, OR 97218 CCN 385045	99	Dec 8, 2025	541 IJ2 harm	$44k
Reedwood Post Acute 3540 SE Francis Street, Portland, OR 97202 CCN 385055	64	Jun 26, 2025	19	—
Hood River Post Acute 729 Henderson Road, Hood River, OR 97031 CCN 385104	100	Mar 13, 2026	371 IJ	$39k
Timberline Post Acute 1023 6th Ave SW, Albany, OR 97321 CCN 385107	67	Feb 13, 2026	26	—
Glisan Post Acute 9750 NE Glisan Street, Portland, OR 97220 CCN 385136	100	Mar 13, 2026	433 harm	—
Woodside Post Acute 301 Ridings Avenue, Molalla, OR 97038 CCN 385150	92	Aug 21, 2026	455 IJ2 open	$116k
Cottage Grove Post Acute 515 Grant Street, Cottage Grove, OR 97424 CCN 385152	80	Jun 27, 2025	312 harm	$21k

No building or property record is linked to this facility yet. Parcel, assessor and building-permit joins will be added only where a valid site match exists.

Coordinates as published by CMS.

Address: 707 SW 37th Street, Pendleton, OR 97801
ZIP: 97801
County: Umatilla County FIPS 41059
State: Oregon
Urban / rural (CMS): Rural

Within ~25 km

Nearby nursing homes

No nearby facilities with coordinates.

Source	Record	Facts	Evidence	Source release	Retrieved
CMS Provider Information US-CMS	385201	name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain	Verified	Oct 1, 2026	Nov 7, 2026
CMS Provider Information US-CMS	385201	ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only.	Verified	Oct 1, 2026	Nov 7, 2026

Record-level source links for CCN 385201

First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction