Facility WatchInspection records for every certified US nursing home
Pilot Butte Rehabilitation Center
1876 NE Highway 20 Bend, OR 97701 (541) 382-5531
Abuse icon
CCN
385138
Certified beds
74
Ownership
For profit - Corporation
Chain
Regency Pacific Management
Nurse staffing
5.12
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 1.14 hours per resident per day
Nursing staff turnover: 56% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected September 19, 2025
8 citations · from a complaint investigation · Health
D
F0552No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected October 21, 2025
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected October 21, 2025
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected October 21, 2025
D
F0628No actual harm with potential for more than minimal harm · Isolated
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Deficient, Provider has date of correction · corrected October 21, 2025
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected October 21, 2025
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected October 21, 2025
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected October 21, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected October 21, 2025
Inspected September 9, 2024
1 citation · from a complaint investigation · Health
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 10, 2024
Inspected May 31, 2024
20 citations · from a complaint investigation · Health
D
F0552No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0561No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0685No actual harm with potential for more than minimal harm · Isolated
Assist a resident in gaining access to vision and hearing services.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0745No actual harm with potential for more than minimal harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected July 20, 2024
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected July 20, 2024
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected July 20, 2024
E
F0803No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected July 20, 2024
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected July 20, 2024
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected July 20, 2024
Inspected April 17, 2024
3 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected May 14, 2024
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected May 14, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 14, 2024
Inspected February 25, 2023
13 citations · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected April 3, 2023
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected April 3, 2023
D
F0659No actual harm with potential for more than minimal harm · Isolated
Provide care by qualified persons according to each resident's written plan of care.
Deficient, Provider has date of correction · corrected April 3, 2023
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected April 3, 2023
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected April 3, 2023
D
F0687No actual harm with potential for more than minimal harm · Isolated
Provide appropriate foot care.
Deficient, Provider has date of correction · corrected April 3, 2023
D
F0726No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 3, 2023
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected April 3, 2023
F
F0658No actual harm with potential for more than minimal harm · Widespread
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected April 3, 2023
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 3, 2023
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 3, 2023
F
F0886No actual harm with potential for more than minimal harm · Widespread
Perform COVID19 testing on residents and staff.
Deficient, Provider has date of correction · corrected April 3, 2023
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected April 3, 2023