Willowbrook Post Acute
Pendleton, Umatilla County, Oregon · CCN 385201 · For-profit (LLC) · part of Pacs Group (274 facilities, chain average 2.9 stars)
CMS rates Willowbrook Post Acute 1 of 5 overall as of August 2026. 59 certified beds, 53 residents a day on average. 43 citations on record from the current inspection cycles, 3 at immediate jeopardy; 2 fines totalling $80,796.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 3 / 2 of 5 |
Staffing
| Total nurse staffing | 5.03286 hours per resident per day |
|---|---|
| Registered nurses | 0.5833 hours per resident per day |
| Weekend total | 4.59066 hours per resident per day |
| Nursing staff turnover | 52.9% (registered nurses 54.5%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-21 complaint survey |
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 · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2026-03-30 |
| 2026-03-19 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-06 |
| 2026-03-19 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-13 |
| 2025-08-22 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 complaint survey |
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 · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | 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 · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 complaint survey |
Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0602 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2024-11-21 |
| 2025-08-22 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | 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 · tag F0605 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | 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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | 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 · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 complaint survey |
Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · tag F0825 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-29 |
| 2025-08-22 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2025-09-29 |
| 2024-05-17 | 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 · tag F0688 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 complaint survey |
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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | 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 · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2024-05-17 | 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 · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-20 |
| 2023-12-07 complaint survey |
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 · tag F0600 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-12-08 |
| 2023-12-07 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-12-08 |
| 2023-12-07 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2023-12-08 |
| 2023-12-07 complaint survey |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · tag F0868 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-12-08 |
| 2023-12-07 complaint survey |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · tag F0835 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-12-08 |
| 2023-12-07 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-08 |
| 2019-12-13 | 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 · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | 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 · tag F0636 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | 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 · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | 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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | 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 · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-01-10 |
| 2019-12-13 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-01-10 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-05-17 | Fine | $61,458 |
| 2023-12-07 | Fine | $19,338 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Truist Bank Organization | 5% or greater security interest | — | 2024-09-01 |
| Deh Enterprises LLC Organization | adp of the snf | — | 2024-09-01 |
| Providence Administrative Consulting Services Inc. Organization | adp of the snf | — | 2024-09-01 |
| Baker, Nicholas Individual | adp of the snf | — | 2026-01-23 |
| Morris, Christopher Individual | adp of the snf | — | 2026-01-23 |
| Apt, Frederick Individual | operational/managerial control | — | 2024-05-10 |
| Baker, Nicholas Individual | operational/managerial control | — | 2024-09-19 |
| Jergensen, Joshua Individual | operational/managerial control | — | 2024-05-10 |
| Mitchell, John Individual | operational/managerial control | — | 2024-05-10 |
| Morris, Christopher Individual | operational/managerial control | — | 2024-09-01 |
| Townsend, Deborah Individual | operational/managerial control | — | 2025-02-17 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Willowbrook Post Acute.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Umatilla County.