Willowbrook Post Acute
WILLOWBROOK POST ACUTE in PENDLETON, OR — inspection on August 22, 2025.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0554 during a standard health inspection conducted on 2025-08-22.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Allow residents to self-administer drugs if determined clinically appropriate.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
incident and he did not know if she/he ever had a one-on-on after the incident.On 8/22/25 at 11:32 AM Staff 1 (Administrator) acknowledged the incident on 3/30/25 with Resident 17 and Resident 63.
Staff 1 stated all residents should be free from aggressive behaviors, including pinching.
Staff 1 stated he expected staff to monitor residents who demonstrate behaviors to limit the possibility of them escalating to the level of abuse.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowbrook Post Acute
707 SW 37th Street Pendleton, OR 97801
SUMMARY STATEMENT OF DEFICIENCIES
Based 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.
Findings include:Resident 26 was admitted to the facility in 6/2024 with diagnoses including infection of the abdominal wall.Resident 26's 6/11/25 Annual MDS indicated the resident was cognitively intact.Resident 26's 11/2025 MAR indicated the resident was to have oxycodone 2.5 mg (a Schedule II controlled pain medication) every four hours as needed for pain.
The facility's investigation dated 11/20/24 included the following:- During a routine narcotic count it was discovered a card of oxycodone belonging to Resident 26 was missing.- It was determined the CMAs and nurses on the night shift were not counting the narcotic drawer properly.- The facility took immediate action to ensure narcotics were counted correctly.- The facility determined misappropriation of Resident 26's personal property occurred, and the claim was substantiated.On 8/19/25 at 9:39 AM Resident 26 stated she/he had not missed any needed oxycodone doses since admission to the facility, and she/he was not aware of any missing oxycodone. On 8/20/25 at 11:03 AM Staff 16 (CMA) stated while performing a narcotic count at shift change, he noticed a card of oxycodone was missing for Resident 26.
Staff 16 stated they had reported the incident to a nurse, and the card was not found. On 8/20/25 at 12:17 PM Staff 3 (RNCM) stated a card of Resident 26's oxycodone was missing and not found.
Staff 3 stated an investigation was conducted and concluded the narcotic drawer was not counted properly, and the card was likely thrown away by mistake.
Staff 3 stated a corrective plan was implemented over the following six weeks.
The deficient practice was identified as Past Noncompliance based on the following:On 11/21/24 the deficient practice was identified and corrected with the following actions:1.
Education and demonstration regarding proper narcotic counting was given to all CMAs. 2.
All CMAs and nurses attested to having reviewed the PharMerica instruction manual regarding the procedure for pulling controlled medications for administration and maintaining the narcotic record book.3.
Weekly narcotic count audits were completed by the DNS for six weeks.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowbrook Post Acute
707 SW 37th Street Pendleton, OR 97801
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0604 during a standard health inspection conducted on 2025-08-22.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-08-22.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-22.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-22.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
During a Resident Council meeting on 8/20/25 at 1:05 PM, attendees expressed concerns regarding long response times from staff during the evening shift.
Resident Council meeting minutes from 5/22/25 concerns with call lights not being answered and staff not coming back after initial response.
Resident Council meeting minutes from 6/2025 revealed concerns with staff taking two hours to answer call lights.
On 8/22/25 at 9:34 AM, Staff 2 (DNS) stated she expected all staff to answer call lights within 15 minutes and acknowledged the ongoing challenges in maintaining appropriate staffing levels.
Staff 2 acknowledged the facility had many residents with high acuity care needs.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowbrook Post Acute
707 SW 37th Street Pendleton, OR 97801
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-08-22.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Post nurse staffing information every day.
Scope/Severity Level B: isolated, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-08-22.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-08-22.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-22.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-22.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
(SLP).
Resident 60's care plan included a goal dated 2/23/24 to work with therapies to increase strength and reinforce cognitive strategies.
Resident 60's therapy evaluation notes revealed she/he was evaluated by PT, OT and SLP who recommended the following therapy schedules:-PT: three days per week-OT: five days per week-SLP: three days per week Resident 60's therapy schedule for the week of 2/25/24 through 3/2/24 revealed the following:-Received two of three PT sessions-Received one of five OT sessions-Received two of three SLP sessions Resident 60's therapy schedule for the week of 3/3/24 through 3/9/24 revealed the following:-Received one of three PT sessions Resident 60's therapy schedule for the week of 3/10/24 through 3/16/24 revealed the following:-Received two of three PT sessions On 8/20/25 at 10:29 AM Staff 13 (Administrative Assistant / Director of Rehabilitation) acknowledged the missed therapy dates and stated PT was out sick during the weeks of 2/25/24 through 3/2/24 and 3/10/24 through 3/16/24 and was not able to complete the scheduled sessions.
Staff 13 was unaware of the reason for the other missed therapy sessions.
On 8/21/25 at 10:12 AM Staff 25 (Regional Director of Rehabilitation) acknowledged the missed therapy sessions and lack of documentation regarding the reason the sessions were missed. He stated therapists sometimes documented in the electronic record and sometimes they did not.
On 8/21/25 at 3:09 PM Witness 6 (Family Member) stated Resident 60 was supposed to receive therapy every day and the staff guaranteed Resident 60 would receive therapy three to four days a week.
On 8/22/25 at 11:32 AM Staff 1 (Administrator) acknowledged Resident 60's missed therapy sessions and stated he expected all residents to receive skilled therapy as ordered.
Refer to F-F725.
Facility ID:
Federal health inspectors cited WILLOWBROOK POST ACUTE in PENDLETON, OR for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-22.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WILLOWBROOK POST ACUTE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.