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Nursing HomeMedicaid Investigative

Willowbrook Post Acute

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

707 Sw 37th Street, Pendleton, OR 9780159 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.8/5

based on 37 Google reviews

5
4
3
2
1
Willowbrook Post Acute Nursing Home in Pendleton, OR — Street View
Street View

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (15 vs median 9.0)
  • High staff turnover (52%)
  • High RN turnover (54%)

Bottom 25% in OR · Meets national RN staffing standard · Above recommended total nurse staffing · Worst in PACS GROUP chain · $80,796 in fines

Source: Medicare data

What this means for your family

While the facility is praised for its rehab program and active administration, the frequency of reports regarding medical neglect and poor communication is concerning. Families should conduct an unannounced visit and specifically ask about their protocols for notifying Power of Attorney during medical emergencies or health status changes.

Google Reviews

Google Reviews

37 reviews on Google
Willowbrook Post Acute receives highly polarized feedback, with some families praising the administration and rehab staff while others report severe neglect and communication failures. Recurring complaints involve poor responsiveness to call lights, inadequate medical oversight for conditions like infections, and unprofessional conduct by nursing staff. Families considering this facility should be aware of significant inconsistencies in the quality of care provided.

Quality Themes

Tap a score for details
Food2.0Staff4.0Clean6.0Activities8.0Meds2.0MemoryN/AComms2.0Value1.0

Strengths

  • Responsive and caring rehab therapy team
  • Visible and engaged facility administrator
  • Helpful and polite nursing staff in specific instances
  • Clean and well-maintained building

Concerns

  • Neglect of medical needs and lack of communication regarding health status (mentioned by 6 reviewers)
  • Slow response times to call lights and patient assistance requests (mentioned by 3 reviewers)
  • Unprofessional or rude behavior by nursing and administrative staff (mentioned by 4 reviewers)
  • Poor food quality and inadequate portion sizes (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2341.0'16(2)1.02.5'18(2)3.75.0'22(6)3.02.3'25(3)4.5'26(16)

Distribution · 44 analyzed

5
28
4
3
3
0
2
0
1
13

How They Respond to Reviews

47%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1Given the facility's focus on rehab, how does the therapy team coordinate with the nursing staff to ensure consistent care throughout the day?
  • 2I noticed the facility has a very active administrator; what is your process for keeping families updated on a loved one's health status and changes in condition?
  • 3Could you walk me through your protocol for responding to call lights and how you ensure residents receive timely assistance when they need it?
  • 4What steps are being taken to improve the quality and variety of the dining experience for residents?
  • 5How do you handle medication management and ensure that medical needs are addressed promptly, especially during evening or weekend hours?
  • 6What opportunities are there for residents to socialize and participate in activities outside of their daily rehabilitation sessions?

Personalized based on this facility's data


Key Review Excerpts

She says that the food is horrible and that the staff has been inattentive to her needs on a constant basis. She turns on her call light and waits for long periods of time to get help to use the toilet.

Memory care family member · 2024☆☆☆☆

The administrator listens and wants to help in any way. The physical therapy department head is also phenomenal. I also really appreciate all of the thoughtful activities planned weekly.

Long-term resident · 2026★★★★★

She developed c-diff symptoms 3 weeks ago and we were not informed and they did NOTHING. This last weekend we were packing her apartment to move her closer to us. They sent her to the hospital “at her request “ and didn’t even notify us as we are her medical power of attorney.

Long-term resident's family · 2026☆☆☆☆
Source: 37 Google reviews

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

11

measures

Worse Than Avg

5

measures

Mixed Results

1

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility35.2%
Worse than Avg
Here
35.2%
US
15.3%
OR
22.5%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility27.1%
Worse than Avg
Here
27.1%
US
15.5%
OR
14.0%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility31.0%
Worse than Avg
Here
31.0%
US
19.4%
OR
22.1%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility11.6%
Better than Avg
Here
11.6%
US
19.5%
OR
12.5%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility19.5%
Worse than Avg
Here
19.5%
US
14.4%
OR
15.3%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility98.6%
Better than Avg
Here
98.6%
US
93.4%
OR
95.3%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility89.4%
Better than Avg
Here
89.4%
US
81.8%
OR
85.5%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility77.9%
Worse than Avg
Here
77.9%
US
79.8%
OR
81.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.5%
Better than Avg
Here
0.5%
US
1.6%
OR
1.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
2penalties
Well above state avg (10.4)
14 complaint-triggered
$80,796 in fines

Families reported multiple concerns leading to 11 complaint-triggered deficiencies, including serious issues with abuse protection and neglect reporting that prompted investigations. The facility shows recurring problems with medication management, nursing staffing, and care planning across all surveys from 2019 to 2025, indicating persistent systemic issues. While the facility reports correcting deficiencies, the pattern of repeated violations in core care areas suggests ongoing operational challenges that families should carefully consider.

Apr 21, 2026Complaint
1
0580Potential for harm · IsolatedResolved (past non-compliance)

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Mar 19, 2026Complaint
2
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Aug 22, 2025Complaint
4
0725Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0602Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0825Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Aug 22, 2025Routine
11
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0604Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

0605Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0732Minimal · PatternCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

May 17, 2024Routine
11
0688Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0341Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

0372Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

May 17, 2024Complaint
1
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Federal Penalties

Fine

May 17, 2024

$61,458

Fine

Dec 7, 2023

$19,338

Ownership & Operations

Who Operates This Facility

Owner / Operator

Willowbrook Post Acute

Organization Type

for profit

Chain Affiliation

Chain Name

Pacs Group

Chain Size

280 facilities nationwide

Chain avg rating: 2.9/5 · Rank 222 of 260 (Worst)

Ownership & Management

Key personnel

Truist Bank5% or Greater Security InterestApt, FrederickManagerBaker, NicholasManagerJergensen, JoshuaManagerMitchell, JohnManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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