Pilot Butte Rehabilitation Center
Pilot Butte Rehabilitation Center is a 2-star rated nursing home in Bend, OR with 74 beds. CMS sub-ratings: health inspections 2/5, staffing 4/5, quality measures 3/5.
The facility has 59 health violations on record. Most recent inspection: May 31, 2024.
This facility has abuse citations on its federal record.
Staff turnover rate: 63.5% — significantly above the national average.
Data synthesized from CMS.gov and Oregon public inspection records. Reviewed by Christopher F. Nesbitt, Sr., NR-EMT & BU-trained Paralegal.
Our Coverage of Pilot Butte Rehabilitation Center
Inspection History Overview
Data current as of May 8, 2026 · Source: CMS Provider Data
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
Health Violations by Year
2024 23 violations
Ensure that residents are fully informed and understand their health status, care and treatments.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Assist a resident in gaining access to vision and hearing services.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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.
Ensure that residents are free from significant medication errors.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
2023 13 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care by qualified persons according to each resident's written plan of care.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate foot care.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Perform COVID19 testing on residents and staff.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
2018 4 violations
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
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.
Provide and implement an infection prevention and control program.
2017 7 violations
Give residents a notice of rights, rules, services and charges.
Reasonably accommodate the needs and preferences of each resident.
Ensure each resident receives an accurate assessment by a qualified health professional.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
2016 12 violations
Ensure that residents are fully informed and understand their health status, care and treatments.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Protect each resident from mistreatment, neglect and misappropriation of personal property.
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
Frequently Asked Questions About Pilot Butte Rehabilitation Center
- What violations has Pilot Butte Rehabilitation Center received?
- Pilot Butte Rehabilitation Center has 59 health and safety violation(s) documented by CMS inspections. All violation data comes from official Medicare inspection reports and is updated regularly from government sources.
- What is the quality rating of Pilot Butte Rehabilitation Center?
- Pilot Butte Rehabilitation Center has a 2-star rating out of 5 from CMS. This rating indicates the facility may have quality concerns that should be investigated further. The rating is based on health inspections, staffing levels, and quality measures.
- When was Pilot Butte Rehabilitation Center last inspected?
- Inspection reports are documented by state survey agencies and the Centers for Medicare & Medicaid Services (CMS). Reports typically lag 2-3 months behind the actual inspection date. Visit the facility's full profile page for detailed violation information and inspection history.
- Is Pilot Butte Rehabilitation Center safe?
- Safety at Pilot Butte Rehabilitation Center should be evaluated based on multiple factors: the facility's CMS rating, recent violation history, and personal visits. We recommend reviewing the complete inspection history, speaking with current residents and families, consulting healthcare professionals, and visiting in person before making placement decisions.
- How do I contact Pilot Butte Rehabilitation Center?
- Phone: (541) 382-5531. Address: 1876 Ne Highway 20, Bend, OR. For visiting hours and admission information, call the facility directly.
- What services does Pilot Butte Rehabilitation Center offer?
- Pilot Butte Rehabilitation Center is a skilled nursing facility with 74 beds. The facility accepts Medicare and Medicaid. For specific services like rehabilitation, memory care, or short-term recovery, contact the facility directly.
- What are better facilities near Bend, OR?
- Compare Pilot Butte Rehabilitation Center with other nursing homes in Bend, OR on our facilities page. Filter by star rating, bed count, and recent inspection results to find the best match for your needs.
Compare Nursing Homes in Bend, OR
| Facility | Rating | Violations | Beds |
|---|---|---|---|
| Pilot Butte Rehabilitation Center (this facility) | ★★☆☆☆ | 59 | 74 |
| Bend Transitional Care | ★★★★★ | 46 | 60 |
| Regency Care Of Central Oregon | ★★★★★ | 46 | 46 |
| Regency Care Of Central Oregon | ★★★★★ | 0 | 87 |
Editorial Standards & Data Oversight
Data Source: This report is based on official public inspection records from the Centers for Medicare & Medicaid Services (CMS) Provider Data Catalog.
Editorial Process: Content generated using AI to synthesize complex regulatory data, then reviewed and verified for accuracy by our editorial team.
Professional Review: All content undergoes standards and compliance oversight by Christopher F. Nesbitt, Sr., Nationally Registered EMT & BU-trained Paralegal, using professional regulatory data auditing protocols.
This page is maintained by NursingHomeNews.org and is not affiliated with Pilot Butte Rehabilitation Center.