Pilot Butte Rehabilitation Center
1876 Ne Highway 20 · Bend, OR · 97701 · 5413825531
74 certified beds For profit - Corporation Chain: Regency Pacific Management
Why this verdict
- Carries CMS’s abuse warning icon.
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.99 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.11 | 0.55–0.75 |
| Weekend hours / resident-day | 4.17 | ≈ weekday level |
| Nursing turnover / year | 56% | median 45% |
| Fines (3-yr window) | 1 · $8,827 |
Inspection citations (45 in the current record)
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Potential for harm · D September 19, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected October 21, 2025 · Resident Rights
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Potential for harm · D September 19, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected October 21, 2025 · Resident Rights
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Potential for harm · D September 19, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 21, 2025 · Quality of Life and Care
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Potential for harm · E September 19, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 21, 2025 · Quality of Life and Care
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Potential for harm · E September 19, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 21, 2025 · Nutrition and Dietary
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Potential for harm · D September 19, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 19, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected October 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E September 19, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected October 21, 2025 · Infection Control
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Immediate jeopardy · J September 9, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 10, 2024 · Quality of Life and Care
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Potential for harm · D May 31, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected July 20, 2024 · Resident Rights
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Potential for harm · D May 31, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected July 20, 2024 · Resident Rights
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Potential for harm · D May 31, 2024
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 July 20, 2024 · Resident Rights
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Potential for harm · D May 31, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected July 20, 2024 · Resident Rights
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Potential for harm · E May 31, 2024
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 July 20, 2024 · Resident Rights
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Potential for harm · D May 31, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected July 20, 2024 · Resident Assessment and Care Planning
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Potential for harm · D May 31, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 20, 2024 · Quality of Life and Care
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Potential for harm · D May 31, 2024
Assist a resident in gaining access to vision and hearing services.
Corrected July 20, 2024 · Quality of Life and Care
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Potential for harm · D May 31, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 20, 2024 · Quality of Life and Care
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Potential for harm · D May 31, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 20, 2024 · Quality of Life and Care
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Potential for harm · D May 31, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected July 20, 2024 · Quality of Life and Care
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Potential for harm · D May 31, 2024
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected July 20, 2024 · Quality of Life and Care
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Potential for harm · D May 31, 2024
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 July 20, 2024 · Pharmacy Service
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Potential for harm · D May 31, 2024
Ensure that residents are free from significant medication errors.
Corrected July 20, 2024 · Pharmacy Service
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Potential for harm · E May 31, 2024
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 July 20, 2024 · Nutrition and Dietary
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Potential for harm · E May 31, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected July 20, 2024 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| September 9, 2024 | Fine | $8,827 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385138 · certified since May 1, 1978. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.