Inspection Reports for
Willowbrook Post Acute

707 SW 37th Street, Pendleton, OR, 97801

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Inspection Report — Aug 22, 2025

Complaint Investigation
Census: 53 Capacity: 59 Deficiencies: 19 Date: Aug 22, 2025

Visit Reason
Seventeen deficiencies identified including issues with resident self-administration of medications, abuse and neglect, misappropriation, physical and chemical restraints, care planning, accident hazards, nursing staff sufficiency, medication errors, food safety, therapy services, infection prevention, and reporting. Most deficiencies were corrected by 9/17/2025.

Findings
Seventeen deficiencies identified including issues with resident self-administration of medications, abuse and neglect, misappropriation, physical and chemical restraints, care planning, accident hazards, nursing staff sufficiency, medication errors, food safety, therapy services, infection prevention, and reporting. Most deficiencies were corrected by 9/17/2025.

Deficiencies (19)
F0000 - INITIAL COMMENTS
F0554 - Resident Self-Admin Meds-Clinically Approp
F0600 - Free from Abuse and Neglect
F0602 - Free from Misappropriation/Exploitation
F0604 - Right to be Free from Physical Restraints
F0605 - Right to be Free from Chemical Restraints
F0656 - Develop/Implement Comprehensive Care Plan
F0689 - Free of Accident Hazards/Supervision/Devices
F0725 - Sufficient Nursing Staff
F0732 - Posted Nurse Staffing Information
F0756 - Drug Regimen Review, Report Irregular, Act On
F0759 - Free of Medication Error Rts 5 Prcnt or More
F0761 - Label/Store Drugs and Biologicals
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0825 - Provide/Obtain Specialized Rehab Services
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report — Jul 9, 2024

Complaint Investigation
Census: 53 Capacity: 59 Deficiencies: 2 Date: Jul 9, 2024

Visit Reason
No deficiencies identified. Two citations noted as initial comments with visit history showing not corrected status.

Findings
No deficiencies identified. Two citations noted as initial comments with visit history showing not corrected status.

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report — May 17, 2024

Complaint Investigation
Census: 53 Capacity: 59 Deficiencies: 14 Date: May 17, 2024

Visit Reason
Eleven deficiencies identified including failure to implement care plans, provide ADL care, quality of care, accident hazards, respiratory care, drug regimen review, medication errors, food safety, staffing, and administrative rules. Some deficiencies corrected by 6/7/2024, others not corrected.

Findings
Eleven deficiencies identified including failure to implement care plans, provide ADL care, quality of care, accident hazards, respiratory care, drug regimen review, medication errors, food safety, staffing, and administrative rules. Some deficiencies corrected by 6/7/2024, others not corrected.

Deficiencies (14)
F0000 - INITIAL COMMENTS
F0656 - Develop/Implement Comprehensive Care Plan
F0677 - ADL Care Provided for Dependent Residents
F0684 - Quality of Care
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0689 - Free of Accident Hazards/Supervision/Devices
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0756 - Drug Regimen Review, Report Irregular, Act On
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0759 - Free of Medication Error Rts 5 Prcnt or More
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report — Feb 12, 2024

Census: 53 Capacity: 59 Deficiencies: 1 Date: Feb 12, 2024

Visit Reason
One deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Findings
One deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report — Jan 2, 2024

Census: 53 Capacity: 59 Deficiencies: 1 Date: Jan 2, 2024

Visit Reason
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Findings
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report — Dec 7, 2023

Complaint Investigation
Census: 53 Capacity: 59 Deficiencies: 9 Date: Dec 7, 2023

Visit Reason
Six deficiencies including abuse and neglect, failure to report and investigate abuse allegations, failure to prevent abuse, failure to ensure resident rights, and failure of administration to implement policies to prevent abuse. Some deficiencies corrected, others not corrected.

Findings
Six deficiencies including abuse and neglect, failure to report and investigate abuse allegations, failure to prevent abuse, failure to ensure resident rights, and failure of administration to implement policies to prevent abuse. Some deficiencies corrected, others not corrected.

Deficiencies (9)
F0000 - INITIAL COMMENTS
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
F0658 - Services Provided Meet Professional Standards
F0835 - Administration
F0868 - QAA Committee
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report — Nov 6, 2023

Census: 53 Capacity: 59 Deficiencies: 1 Date: Nov 6, 2023

Visit Reason
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Findings
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report — Sep 25, 2023

Census: 53 Capacity: 59 Deficiencies: 1 Date: Sep 25, 2023

Visit Reason
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Findings
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report — May 15, 2023

Census: 53 Capacity: 59 Deficiencies: 1 Date: May 15, 2023

Visit Reason
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Findings
One deficiency for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency not corrected at revisit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

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