Nursing home report card · Bend, OR
Pilot Butte Rehabilitation Center
1876 NE Highway 20, Bend, OR 97701
Call this home: (541) 382-5531
View this home on Medicare.gov ↗
Quick summary
Medicare shows an abuse warning
Medicare’s Care Compare site shows an abuse icon here. That is one of the strongest public warnings CMS publishes — dig into the inspection history and talk with an attorney if a loved one was hurt.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Sep 19, 2025
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Among the lowest Medicare ratings
Based on problems found during health inspections.
Among the lowest Medicare ratings
Based on staffing levels and related measures.
Above average
Based on reported health and care results.
About average for U.S. nursing homes
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 385138
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Immediate danger to residents · isolated case
Sep 9, 2024 · Inspection rule 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Caused actual harm · isolated case
Feb 25, 2023 · Inspection rule 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Could have caused harm · isolated case
Jun 24, 2026 · Inspection rule 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 57 minutes per resident per day
about 4 hr 53 min per resident per day
about 44 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 1 stars
- Health inspection rating: 1 stars
- Staffing rating: 4 stars
- Registered nurse time per resident: 0.94 hours/day
- Total nurse time per resident: 4.89 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; Oregon averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Medicare shows an abuse warning icon for this home
- Overall star rating is 2 or lower
- Health inspection rating is 2 stars or lower
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
- CMS has fined this home in the recent reporting period
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Immediate danger to residents1 citation
- Caused actual harm1 citation
- Could have caused harm48 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 50
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Corporation.
- We do not have individual owner names for this home.
Other homes in this group: All Regency Pacific Management nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
June 24, 20265 findings
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code E
Respond appropriately to all alleged violations.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0602 · code D
Protect each resident from the wrongful use of the resident's belongings or money.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0627 · code D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
September 19, 20258 findings
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0552 · code D
Ensure that residents are fully informed and understand their health status, care and treatments.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0628 · code D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code E
Provide and implement an infection prevention and control program.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
September 9, 20241 finding
- Quality of Life and Care problemsImmediate danger to residents · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
May 31, 202420 findings
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0698 · code D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0745 · code D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0758 · code D
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…
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code E
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.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0803 · code E
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.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0804 · code E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0552 · code D
Ensure that residents are fully informed and understand their health status, care and treatments.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0561 · code D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0578 · code D
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.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0582 · code D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0685 · code D
Assist a resident in gaining access to vision and hearing services.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0806 · code D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0883 · code D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code D
Ensure that residents are free from significant medication errors.
April 17, 20243 findings
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code D
Respond appropriately to all alleged violations.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
February 25, 202313 findings
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Resident Assessment and Care Planning problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code F
Ensure services provided by the nursing facility meet professional standards of quality.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Infection Control problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code F
Provide and implement an infection prevention and control program.
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0921 · code E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0580 · code D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0659 · code D
Provide care by qualified persons according to each resident's written plan of care.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0677 · code D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Infection Control problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0886 · code F
Perform COVID19 testing on residents and staff.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0687 · code D
Provide appropriate foot care.
- Nursing and Physician Services problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0726 · code D
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.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Fine · Sep 9, 2024$8,827
Other homes in this chain
Regency Pacific Management · other locations in Oregon
- Regency Albany · Albany2 of 5 · 33 problems
- Regency Hermiston Nursing & Rehab Center · Hermiston3 of 5 · 26 problems
- Laurel Hill Nursing Center · Grants Pass3 of 5 · 29 problems
- Regency Florence · Florence4 of 5 · 30 problems
- Regency Care of Central Oregon · Bend5 of 5 · 22 problems
- Regency Prineville Rehabilitation and Nursing Cent · Prineville5 of 5 · 8 problems
- Regency Redmond Rehabilitation and Nursing Center · Redmond5 of 5 · 30 problems
- Regency Gresham Nursing & Rehabilitation Center · Gresham5 of 5 · 21 problems
Related topics
Questions about Pilot Butte Rehabilitation Center
What is Pilot Butte Rehabilitation Center's Medicare star rating?
Has Pilot Butte Rehabilitation Center been fined?
Does Pilot Butte Rehabilitation Center have a Medicare abuse warning?
How does Pilot Butte Rehabilitation Center compare with other nursing homes in Oregon?
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