Pilot Butte Rehabilitation Center
Bend, Deschutes County, Oregon · CCN 385138 · For-profit (Corporation) · part of Regency Pacific Management (27 facilities, chain average 3.9 stars)
CMS rates Pilot Butte Rehabilitation Center 1 of 5 overall as of August 2026. 74 certified beds, 41 residents a day on average. 50 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $8,827.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 2 / 4 of 5 |
Staffing
| Total nurse staffing | 4.8869 hours per resident per day |
|---|---|
| Registered nurses | 0.94283 hours per resident per day |
| Weekend total | 3.94174 hours per resident per day |
| Nursing staff turnover | 50.8% (registered nurses 27.3%) |
| Administrators who left | 2 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-24 complaint survey |
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 Deficiencies · tag F0600 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has plan of correction 2026-07-14 |
| 2026-06-24 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has plan of correction 2026-07-14 |
| 2026-06-24 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has plan of correction 2026-07-14 |
| 2026-06-24 complaint survey |
Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0602 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2026-01-18 |
| 2026-06-24 complaint survey |
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Resident Rights Deficiencies · tag F0627 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2026-07-14 |
| 2025-09-19 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-10-21 |
| 2025-09-19 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-10-21 |
| 2025-09-19 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-10-21 |
| 2025-09-19 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-21 |
| 2025-09-19 complaint survey |
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 Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-21 |
| 2025-09-19 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-21 |
| 2025-09-19 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-21 |
| 2025-09-19 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-10-21 |
| 2024-09-09 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-09-10 |
| 2024-05-31 | 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | 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 Deficiencies · tag F0803 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | 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 Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · tag F0582 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 complaint survey |
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 Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | 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 Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · tag F0745 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-05-31 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-20 |
| 2024-04-17 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-14 |
| 2024-04-17 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-14 |
| 2024-04-17 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-14 |
| 2023-02-25 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Perform COVID19 testing on residents and staff. Infection Control Deficiencies · tag F0886 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | 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 Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Provide care by qualified persons according to each resident's written plan of care. Resident Assessment and Care Planning Deficiencies · tag F0659 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | Provide appropriate foot care. Quality of Life and Care Deficiencies · tag F0687 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-03 |
| 2023-02-25 | 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. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-03 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-09-09 | Fine | $8,827 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Bd Facilities LLC Organization | 5% or greater direct ownership interest | 100% | 2010-04-01 |
| Bd Facilities LLC Organization | adp of the snf | — | 2026-02-19 |
| Omnicare LLC Organization | adp of the snf | — | 2013-09-01 |
| Regency Pacific Management LLC Organization | adp of the snf | — | 2025-08-26 |
| Regency Pacific Management LLC Organization | operational/managerial control | — | 2010-01-01 |
| Beddoe, Marvin Individual | 5% or greater indirect ownership interest | 99% | 2017-04-01 |
| Beddoe, Marvin Individual | adp of the snf | — | 2016-06-01 |
| Beddoe, Sandra Individual | adp of the snf | — | 2017-05-01 |
| Johnson, Sarah Individual | adp of the snf | — | 2023-09-05 |
| Rapp, Andrew Individual | adp of the snf | — | 2016-03-08 |
| Suarez, Yolanda Individual | adp of the snf | — | 2026-02-01 |
| Beddoe, Sandra Individual | indirect ownership interest | — | 2017-05-01 |
| Beddoe, Marvin Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2026-03-10 |
| Beddoe, Marvin Individual | operational/managerial control | — | 2016-06-01 |
| Johnson, Sarah Individual | operational/managerial control | — | 2023-09-05 |
| Rapp, Andrew Individual | operational/managerial control | — | 2016-03-08 |
| Suarez, Yolanda Individual | operational/managerial control | — | 2026-02-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Pilot Butte Rehabilitation Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Deschutes County.