Willowbrook Post Acute
Inspection Findings
F-Tag F0554
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.
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm
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.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowbrook Post Acute
707 SW 37th Street Pendleton, OR 97801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0602
F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm or potential for actual harm
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.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowbrook Post Acute
707 SW 37th Street Pendleton, OR 97801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0604
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.
F-Tag F0605
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.
F-Tag F0656
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.
F-Tag F0689
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.
F-Tag F0725
F 0725 Level of Harm - Minimal harm or potential for actual harm
- 4. Resident 9 was admitted to the facility on 6/2025 with diagnosis including Parkinsons and difficulty
- 5. During a Resident Council meeting on 8/20/25 at 1:05 PM, attendees expressed concerns regarding long
walking.
The Dementia Cognitive Loss CAA dated 6/11/25 revealed Resident 9 had severe cognitive impairment and metabolic encephalopathy (the brain is not functioning properly due to a chemical imbalance.)
Residents Affected - Some
On 8/20/25 at 2:32 PM, Staff 24 (CNA) and Staff 28 (CNA) both stated Resident 9 was a fall risk, experienced confusion, required two-person assistance with transfers and was dependent on staff for all ADL care needs. Staff 24 and Staff 28 indicated the facility was often severely understaffed during evenings and weekends and both were assigned beyond the state minimum staffing ratios.
On 8/20/25 at 8:33 PM, Resident 9 was observed up in her/his wheelchair sitting outside her/his room. At 8:45 PM, Staff 31 (LPN) spoke with Resident 9 who stated she/he needed to use the bathroom and wanted to go to bed. Staff 31 requested assistance for Resident 9 and was informed the assigned CNA was providing a shower to another resident. At 9:16 PM, two staff members assisted Resident 9 into her/his bedroom and closed the door. At 9:33 PM, (approximately 45 minutes later), the resident was in bed, with
the bed in the lowest position and call light within reach.
On 8/20/25 at 9:36 PM Staff 47 (CNA) stated evening shifts were rough. Staff 47 stated it was difficult assisting residents and responding to call lights in a timely manner. Staff 47 stated residents were upset due to long wait times and inadequate staffing. Staff 47 stated multiple residents in the facility required two-person assistance or were fully dependent on staff for ADL care needs.
On 8/21/25 at 2:42 PM, Staff 3 (RNCM) stated staff were expected to answer call lights within five to 10 minutes. Staff 3 acknowledged staffing concerns and the facility had residents with high acuity needs.
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.
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowbrook Post Acute
707 SW 37th Street Pendleton, OR 97801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0732
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.
F-Tag F0756
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.
F-Tag F0759
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.
F-Tag F0761
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.
F-Tag F0812
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.
F-Tag F0825
F 0825
(SLP).
Level of Harm - Minimal harm or potential for actual harm
Resident 60's care plan included a goal dated 2/23/24 to work with therapies to increase strength and reinforce cognitive strategies.
Residents Affected - Few
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0880
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.
WILLOWBROOK POST ACUTE in PENDLETON, OR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PENDLETON, OR, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WILLOWBROOK POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.