Bend, OR

Pilot Butte Rehabilitation Center

2-star overall rating with 2-star inspections with abuse icon flag with $8,827 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1876 Ne Highway 20, Bend, OR

(541) 382-5531

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

74

Certified beds

Average residents

43

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Regency Pacific Management

Operator or chain grouping

Approved since

1978-05-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.11

Registered nurse staffing

LPN hours / resident day

0.81

Licensed practical nurse staffing

Aide hours / resident day

2.94

Nurse aide staffing

Weekend hours

4.01

Weekend nurse staffing

RN turnover

57%

Annual RN turnover

Total nurse turnover

55%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.3%
95.5%
2.8 pts better
93.4%
4.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 68.8%
95.2%
26.4 pts worse
95.5%
26.7 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 0.0%
2.4%
2.4 pts better
3.3%
3.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 8.2%
4.7%
3.5 pts worse
11.4%
3.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 2.0%
5.0%
3 pts better
5.4%
3.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 6.1%
12.5%
6.4 pts better
19.6%
13.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 6.5%
14.7%
8.2 pts better
16.7%
10.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 36.5%
24.1%
12.4 pts worse
16.3%
20.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 25.8%
15.8%
10 pts worse
14.9%
10.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 6.7%
1.7%
5 pts worse
1.0%
5.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 3.5%
2.0%
1.5 pts worse
1.7%
1.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 26.6%
22.2%
4.4 pts worse
19.8%
6.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 9.4%
6.5%
2.9 pts worse
5.1%
4.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 95.8%
85.4%
10.4 pts better
81.7%
14.1 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 9.4%
15.1%
5.7 pts better
12.0%
2.6 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 1.2%
1.7%
0.5 pts better
1.6%
0.4 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 76.6%
81.2%
4.6 pts worse
79.7%
3.1 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.0%
21.6%
0.4 pts worse
23.9%
1.9 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-19 · Fire 2025-09-19

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2024-05-31 · Fire 2024-05-31

24 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-02-25 · Fire 2023-02-25

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-09-19

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-09-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-10-21

F · Potential for more than minimal harm 2024-05-31

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-07-19

F · Potential for more than minimal harm 2024-05-31

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-19

F · Potential for more than minimal harm 2024-05-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-19

F · Potential for more than minimal harm 2024-05-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-07-19

F · Potential for more than minimal harm 2024-05-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-07-19

E · Potential for more than minimal harm 2024-05-31

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-07-19

E · Potential for more than minimal harm 2024-05-31

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-19

D · Potential for more than minimal harm 2024-05-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-19

D · Potential for more than minimal harm 2024-05-31

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-07-19

F · Potential for more than minimal harm 2023-02-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-04-03

F · Potential for more than minimal harm 2023-02-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-04-03

E · Potential for more than minimal harm 2023-02-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-04-03

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-19

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-21

E · Potential for more than minimal harm 2025-09-19

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2025-10-21

E · Potential for more than minimal harm 2025-09-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-21

D · Potential for more than minimal harm 2025-09-19

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-10-21

D · Potential for more than minimal harm 2025-09-19

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-10-21

D · Potential for more than minimal harm 2025-09-19

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-10-21

D · Potential for more than minimal harm 2025-09-19

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-21

D · Potential for more than minimal harm 2025-09-19

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-10-21

J · Immediate jeopardy 2024-09-09

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-09-10

E · Potential for more than minimal harm 2024-05-31

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-05-31

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-05-31

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-05-31

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-05-31

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-07-20

D · Potential for more than minimal harm 2024-04-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-05-14

D · Potential for more than minimal harm 2024-04-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-05-14

D · Potential for more than minimal harm 2024-04-17

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-05-14

G · Actual harm 2023-02-25

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-04-03

F · Potential for more than minimal harm 2023-02-25

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-04-03

F · Potential for more than minimal harm 2023-02-25

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-04-03

F · Potential for more than minimal harm 2023-02-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-04-03

F · Potential for more than minimal harm 2023-02-25

F886 · Infection Control Deficiencies

Health

Perform COVID19 testing on residents and staff.

Corrected 2023-04-03

E · Potential for more than minimal harm 2023-02-25

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

F580 · Resident Rights Deficiencies

Health

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

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

F659 · Resident Assessment and Care Planning Deficiencies

Health

Provide care by qualified persons according to each resident's written plan of care.

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2023-04-03

D · Potential for more than minimal harm 2023-02-25

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2023-04-03

Penalties and ownership

What sits behind the stars

$8,827 2024-09-09

Fine

Fine · fine $8,827

Fine

Ownership

Bd Facilities LLC

5% Or Greater Direct Ownership Interest · Organization

100% 9 facilities 2010-04-01
Beddoe, Marvin

5% Or Greater Indirect Ownership Interest · Individual

67% 22 facilities 2017-04-01
Bd Facilities LLC

Operational/Managerial Control · Organization

0% 9 facilities 2010-04-01
Beddoe, Marvin

Operational/Managerial Control · Individual

0% 22 facilities 2017-04-01
Regency Pacific Management LLC

Operational/Managerial Control · Organization

0% 19 facilities 2010-04-01

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Overall
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