Federal inspection record · CMS data as of October 1, 2026
Pilot Butte Rehabilitation Center
1876 Ne Highway 20, Bend, OR · (541) 382-5531
- Cited for abuse (CMS abuse icon)
- Certified beds
- 74
- Residents per day
- 42
- Ownership
- For-Profit
- Chain
- Regency Pacific Management
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 1, 1978
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Oregon.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Oregon homes
Pilot Butte Rehabilitation Center carries 102.75 inspection points. That is fewer than 18% of Oregon's 126 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Oregon: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–14 pts
- 4★ 14–41 pts
- 3★ 41–65 pts
- 2★ 65–95.25 pts
- 1★ over 95.25 pts
Bars show every rated home in Oregon by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
50 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Quality of Life and Care12E
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Assist a resident in gaining access to vision and hearing services.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate foot care.
Freedom from Abuse, Neglect, and Exploitation9E
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- E
Respond appropriately to all alleged violations.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Resident Rights9E
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Nutrition and Dietary6F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control4F
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- F
Provide and implement an infection prevention and control program.
- F
Perform COVID19 testing on residents and staff.
Resident Assessment and Care Planning4F
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Provide care by qualified persons according to each resident's written plan of care.
Pharmacy Service2D
- D
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.
- D
Ensure that residents are free from significant medication errors.
Environmental1E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Nursing and Physician Services1D
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspection history
2025-09-19
13 health deficiencies · 3 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
2024-05-31
20 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2023-02-25
17 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 46 min of nursing staff time a day, 45 min of it from a registered nurse.
This home
4 h 46 min
Oregon average
5 h 8 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 52% of nursing staff and 50% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$8,827 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-09-09 | Fine | $8,827 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.8 pts better | 99.1% | 95.3% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine9.2 pts worse | 84.8% | 94.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.4 pts better | 0.0% | 2.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.2 pts worse | 6.1% | 4.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.2 pts better | 4.4% | 4.6% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.4 pts worse | 19.6% | 12.2% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.2 pts better | 11.1% | 14.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.7 pts worse | 19.3% | 18.6% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.4 pts worse | 17.6% | 14.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder6 pts worse | 7.3% | 1.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.7 pts worse | 2.7% | 2.0% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence6.4 pts better | 14.4% | 20.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.1 pts worse | 6.7% | 5.6% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine11.5 pts better | 97.3% | 85.8% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit9.3 pts better | 6.7% | 16.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts worse | 2.6% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine12.6 pts better | 93.5% | 80.9% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.9 pts worse | 25.8% | 21.9% | 23.4% |
·
Who owns and runs it
17 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bd Facilities LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 9 facilities |
| Beddoe, Marvin | 5% Or Greater Indirect Ownership Interest · Individual | 99% | 21 facilities |
| Bd Facilities LLC | Adp Of The SNF · Organization | 0% | 9 facilities |
| Beddoe, Marvin | Operational/Managerial Control · Individual | 0% | 21 facilities |
| Beddoe, Marvin | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 21 facilities |
| Beddoe, Marvin | Adp Of The SNF · Individual | 0% | 21 facilities |
| Beddoe, Sandra | Indirect Ownership Interest · Individual | 0% | 8 facilities |
| Beddoe, Sandra | Adp Of The SNF · Individual | 0% | 8 facilities |
| Johnson, Sarah | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Johnson, Sarah | Adp Of The SNF · Individual | 0% | 1 facilities |
| Omnicare LLC | Adp Of The SNF · Organization | 0% | 43 facilities |
| Rapp, Andrew | Operational/Managerial Control · Individual | 0% | 13 facilities |
| Rapp, Andrew | Adp Of The SNF · Individual | 0% | 13 facilities |
| Regency Pacific Management LLC | Operational/Managerial Control · Organization | 0% | 20 facilities |
| Regency Pacific Management LLC | Adp Of The SNF · Organization | 0% | 20 facilities |
| Suarez, Yolanda | Operational/Managerial Control · Individual | 0% | 5 facilities |
| Suarez, Yolanda | Adp Of The SNF · Individual | 0% | 5 facilities |
·
Fire safety
18 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems6F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Have proper medical gas storage and administration areas.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
Smoke5F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Provide properly protected cooking facilities.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Miscellaneous2F
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
Egress2E
- E
Meet other general requirements.
- D
Install proper backup exit lighting.
Services1D
- D
Have properly installed electrical wiring and gas equipment.
Emergency Preparedness1F
- F
Address subsistence needs for staff and patients.
Construction1D
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
·
Other homes nearby
-
Bend Transitional Care
Bend, OR · Cascadia Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 51 min
- Fines
- $0
-
Regency Care Of Central Oregon
Bend, OR · Regency Pacific Management
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 5 h 44 min
- Fines
- $0
-
Regency Redmond Rehabilitation And Nursing Center
Redmond, OR · Regency Pacific Management
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 36 min
- Fines
- $0