Nursing homeActive
Pilot Butte Rehabilitation Center
1876 Ne Highway 20, Bend, OR 97701541382553174 certified beds · 41 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
6
since 2023
Deficiencies
50
● 0● 48● 2
Penalties · 3 yrs
$8,827
1 fine
Last survey
2026-06-24
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 4
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Oregon Department of Human Services · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-06-24 | Complaint | 050 | CMS-2567 (Care Compare) | — |
| 2025-09-19 | Standard | 080 | CMS-2567 (Care Compare) | — |
| 2024-09-09 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2024-05-31 | Standard | 0200 | CMS-2567 (Care Compare) | — |
| 2024-04-17 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2023-02-25 | Standard | 0121 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Oregon Department of Human Services publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-14Record 385138-20260624-F600
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-18Record 385138-20260624-F602
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-14Record 385138-20260624-F609
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-07-14Record 385138-20260624-F610
F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-14Record 385138-20260624-F627
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F552
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F609
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F628
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F689
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-21Record 385138-20250919-F880
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-09-10Record 385138-20240909-F689
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F552
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F561
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F578
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F582
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F584
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F600
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F657
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F684
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F685
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F689
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F698
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F745
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F758
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F760
F803Ensure 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.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F803
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F804
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F812
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-20Record 385138-20240531-F883
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-14Record 385138-20240417-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-14Record 385138-20240417-F610
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-14Record 385138-20240417-F689
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-04-03Record 385138-20230225-F686
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F580
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity FStandard
Care planningRecords
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F658
F659Provide care by qualified persons according to each resident's written plan of care.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F659
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F684
F687Provide appropriate foot care.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F687
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F726
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F812
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F880
F886Perform COVID19 testing on residents and staff.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F886
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-04-03Record 385138-20230225-F921
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-09-09 | Civil money penalty | $8,827 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.94
Facility
Oregon
National
Oregon 0.72 · National 0.69
Total nurse hours per resident day4.89
Facility
Oregon
National
Oregon 5.03 · National 3.86
Weekend total nurse hours3.94
Facility
Oregon
National
Oregon 4.51 · National 3.42
Total nursing staff turnover51%
Facility
Oregon
National
Oregon 47% · National 46%
Registered nurse turnover27%
Facility
Oregon
National
Oregon 52% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Oregon | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 8.5% | 5.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 0.0% | 2.4% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 9.8% | 13.9% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 2.7% | 2.0% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 20.8% | 14.9% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 4.1% | 4.7% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 15.5% | 12.4% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Bd Facilities LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Beddoe, Marvin Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 99% | — | — |
| Beddoe, Marvin Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Johnson, Sarah Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Rapp, Andrew Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Regency Pacific Management LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Suarez, Yolanda Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Bd Facilities LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Beddoe, Marvin Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE | — | — |
| Beddoe, Marvin Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Beddoe, Sandra Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Beddoe, Sandra Individual | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Johnson, Sarah Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Omnicare LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Rapp, Andrew Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Regency Pacific Management LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Suarez, Yolanda Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Regency Pacific Management — 27 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Oregon.
No county cost figures on file for Deschutes.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Bend Transitional Care Bend | 1.0 mi | 2025-06-27 | 030 |
| Regency Care Of Central Oregon Bend | 1.3 mi | 2025-12-05 | 070 |
| Regency Redmond Rehabilitation And Nursing Center Redmond | 13.9 mi | 2026-01-16 | 0180 |
| Regency Prineville Rehabilitation and Nursing Cent Prineville | 28.0 mi | 2026-01-16 | 040 |
| Willow Creek Post Acute Madras | 41.0 mi | 2026-02-12 | 030 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |