Pilot Butte Rehabilitation Center
Inspection Findings
F-Tag F0552
Federal health inspectors cited PILOT BUTTE REHABILITATION CENTER in BEND, OR for a deficiency under regulatory tag F-F0552 during a standard health inspection conducted on 2025-09-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of PILOT BUTTE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
F-Tag F0600
F 0600
services and not neglect residents.
Level of Harm - Minimal harm or potential for actual harm
2: Resident 51 was admitted to the facility in 8/2023 with diagnoses including infection.
Residents Affected - Few
On 9/18/25 at 8:30 AM, Staff 21 (CNA) stated she was assisting Staff 24 (CNA) to provide care for Resident 51 on 4/27/25. Staff 21 stated Staff 24 was rough with the resident while placing a chuck (a device used to help reposition a resident) under the resident. She stated Staff 24 told Resident 51 she/he was not exactly easy to move when Resident 51 objected to the rough treatment by Staff 24. Staff 21 stated Staff 24 then jerked the chuck under the resident to reposition him without counting (a method used to be sure staff reposition the resident in unison) and the resident told Staff 24 he was hurting him. Staff 21 stated Staff 24 ignored the resident and left the room after repositioning her/him without providing the resident additional care.
On 9/19/25 at 10:27 AM, Staff 16 (Social Services Director) stated Resident 51 informed her on 4/28/25 that Staff 24 had been abusive to her/him while providing care.
A review of the investigation 5/1/25 by Staff 3 (former Administrator) and Staff 2 (DNS) revealed the facility could not rule out abuse to Resident 51 by Staff 24.
Resident 51 was not available for interview.
An attempt to interview Staff 24 on 9/16/25 was not successful.
Staff 2 was not available for interview.
Attempts to interview Staff 3 on 9/18/25 were not successful.
On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Clinical Operations) acknowledged Resident 51 was abused by Staff 24.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pilot Butte Rehabilitation Center
1876 NE Highway 20 Bend, OR 97701
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
On 9/19/25 at 10:33 AM, Staff 1 (Administrator), Staff 15 (Regional VP) and Staff 11 (Regional Director of Operations) stated allegations of abuse should be reported to the state agency within 2 hours and stated facility records showed the alleged abuse was not reported timely.
- 3. Resident 47 was admitted to the facility in 4/2024 with diagnoses including quadriplegia, Amyotrophic
Lateral Sclerosis (ALS, a progressive disease which affects physical function).
A facility reported incident dated 10/3/24 at 10:00 AM indicated on 10/2/24 at 12:00 PM, Staff 4 (CNA) reported Staff 5 did not provide care to Resident 47 during the night shift on 10/1/24.
Attempts to interview Staff 4 on 9/16/25 and 9/18/25 were unsuccessful.
On 9/16/25 at 11:07 AM, Staff 6 (Former Nurse's Aide Student) stated she observed Staff 5 enter Resident 47's room and turn off the call light during night shift on 10/1/24 without providing care or services. Staff 6 reported the concern to Staff 2 between 6:00 AM and 7:00 AM on 10/2/24.
Staff 2 was not available for interview.
On 9/19/25 at 7:19 AM, Staff 1 (Administrator) stated she would expect staff to report an allegation of neglect to the State agency within 24 hours if no major injury occurred.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pilot Butte Rehabilitation Center
1876 NE Highway 20 Bend, OR 97701
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0628
Federal health inspectors cited PILOT BUTTE REHABILITATION CENTER in BEND, OR for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of PILOT BUTTE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
F-Tag F0684
Federal health inspectors cited PILOT BUTTE REHABILITATION CENTER in BEND, OR for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-09-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of PILOT BUTTE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
F-Tag F0689
Federal health inspectors cited PILOT BUTTE REHABILITATION CENTER in BEND, OR for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-09-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of PILOT BUTTE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
F-Tag F0812
Federal health inspectors cited PILOT BUTTE REHABILITATION CENTER in BEND, OR for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-19.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of PILOT BUTTE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-21.
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm
personnel must wear gloves and gown for high contact resident care activities including bathing, transferring, changing linens, assisting with toileting and providing hygiene.
On 9/19/25 at 7:14 AM, Staff 11 (Regional Director of Clinical Operations) stated staff were expected to follow the EBP sign and policy for using the proper PPE while caring for a resident.
Residents Affected - Some b. On 9/18/25 at 2:01 PM, Staff 18 (Hospice RN) was overheard informing Resident 1 her/his catheter was leaking, and she was going to turn on the light to change the catheter. Staff 18 was observed wearing gloves but no gown. At 2:19 PM, Staff 18 removed her gloves; no gown was observed. Staff 18 confirmed
she changed Resident 1's catheter and wore only gloves. She acknowledged a gown should be worn
during catheter care.
On 9/19/25 at 7:14 AM Staff 11 (Regional Director of Clinical Operations) stated staff were expected to follow the EBP sign and policy for using the proper PPE while caring for residents.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
PILOT BUTTE REHABILITATION CENTER in BEND, OR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BEND, OR, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PILOT BUTTE REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.