Pilot Butte Rehabilitation Center
1876 NE Highway 20, Bend, OR 97701
Pilot Butte Rehabilitation Center, a 74-bed for profit - corporation nursing facility in Bend, OR, holds a 2-star CMS overall rating - below the 3.0-star national average, with nurse staffing above the national norm. 2 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 5413825531
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- 2 / 5
- Below average · CMS overall · nat'l 3.0
- 4.86
- Well above average · nurse hrs/day · nat'l 3.89
- 45
- Inspection findings · 2 serious
- $9K
- Federal penalties (1)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 385138
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 74
- Residents
- 43
- In Hospital
- No
- County
- Deschutes
- Last Inspection
- Sep 19, 2025
Staffing Data
How the 4.86 total nursing hours per resident-day are staffed:
- RN Hours
- 1.11 (nat'l avg: 0.68)
- LPN Hours
- 0.81
- CNA Hours
- 2.94
- Total Nursing Hours
- 4.86 (nat'l avg: 3.89)
- PT Hours
- 0.10
- Nursing Turnover
- 54.7%
- RN Turnover
- 57.1%
What the CMS Record Reveals About Pilot Butte Rehabilitation Center
Pilot Butte Rehabilitation Center operates 74 certified beds in Bend, OR with approximately 43 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (4★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 45 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $9K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.86 total nursing hours per resident day (national average 3.89), with RN coverage at 1.11 per resident day, the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Pilot Butte Rehabilitation Center falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 54.7%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (45 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 21, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 21, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 21, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 21, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 21, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 21, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Oct 21, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Oct 21, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 10, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 20, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Jul 20, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 20, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 20, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 20, 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.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 20, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Jul 20, 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.
Category: Pharmacy Service Deficiencies
Corrected: Jul 20, 2024
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 20, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 20, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 20, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 20, 2024
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 20, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 20, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 20, 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.
Category: Resident Rights Deficiencies
Corrected: Jul 20, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Jul 20, 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.
Category: Resident Rights Deficiencies
Corrected: Jul 20, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Jul 20, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Jul 20, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 14, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 14, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 14, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 3, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Apr 3, 2023
Perform COVID19 testing on residents and staff.
Category: Infection Control Deficiencies
Corrected: Apr 3, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 3, 2023
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 3, 2023
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2023
Provide care by qualified persons according to each resident's written plan of care.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 3, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 3, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 3, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Apr 3, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 25.8% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 6.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.5% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 36.5% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 9.4% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 6.5% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.0% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 8.2% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 98.3% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 6.1% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 68.8% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 26.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 95.8% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 76.6% | No |
Penalty History 1 penalties totaling $9K
| Date | Type | Amount |
|---|---|---|
| Sep 9, 2024 | Fine | $9K |
| Feb 25, 2023 | Fine | $11K |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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