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Pilot Butte Rehabilitation Center

Skilled nursing facility and nursing facility

1876 NE Highway 20
Bend, OR 97701

Report Date
Nov 1, 2026
Data Through
Oct 1, 2026
Report ID
VR-OR-385138-2611
← Pilot Butte Rehabilitation Center, free profile

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The Vardell Report.Pilot Butte Rehabilitation Center

The deeper story, beautifully organized. Available records, historical context, and questions worth asking.

Provider Category
Nursing home
Location
Bend, OR
Record Period
2023–2026
Source Documents
8
Read the report

This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.

01

The Essentials

Summary

Across 6 inspections from February 2023 to June 2026, state surveyors documented 50 findings at Pilot Butte Rehabilitation Center; 50 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections
6
2023–2026, complaint and standard
Findings
50
Deficiencies cited by state inspectors
Corrected
50
Of 50 findings, with a recorded correction date
Penalties
1
1 fine; payment not published

Findings by Year

  • Findings
  • Of which, actual harm (level G or above)
2023: 13 findings across 1 inspection; of which, actual harm (level G or above): 11320231 inspection2024: 24 findings across 3 inspections; of which, actual harm (level G or above): 12420243 inspections2025: 8 findings across 1 inspection820251 inspection2026: 5 findings across 1 inspection52026*1 inspection2023: 13 findings across 1 inspection; of which, actual harm (level G or above): 11320231 insp.2024: 24 findings across 3 inspections; of which, actual harm (level G or above): 12420243 insp.2025: 8 findings across 1 inspection820251 insp.2026: 5 findings across 1 inspection52026*1 insp.

* Partial year, through October 1, 2026.

Findings by year
YearInspectionsFindingsOf which, actual harm (level G or above)
20231131
20243241
2025180
2026150

What the Record Shows

  • 50 of 50 findings have a recorded correction date.
  • CMS lists 1 enforcement action in the window: 1 fine of $8,827, its payment not published.
  • 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
  • The latest standard inspection, September 19, 2025, recorded 8 findings (most serious: Level E).

What to Ask About

Report at a Glance

Facility
Pilot Butte Rehabilitation Center
Address
1876 NE Highway 20, Bend, OR 97701
CMS Certification Number
385138
Provider Type
Skilled nursing facility and nursing facility
Certified Beds
74
Ownership
For profit - Corporation
Record Window
February 25, 2023 to October 1, 2026
02

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

  1. 2026

    Complaint investigation

    5 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected Jul 14, 2026
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Jul 14, 2026
    • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Jul 14, 2026
    • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Jan 18, 2026
    • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level DNo actual harm, potential for moreCorrected Jul 14, 2026

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  2. 2025

    Standard health inspection

    8 findings

    The same visit included a complaint investigation.

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Oct 21, 2025
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Oct 21, 2025
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 21, 2025
    • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Oct 21, 2025
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Oct 21, 2025
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 21, 2025
    • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Oct 21, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 21, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  3. 2024

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Sep 10, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  4. 2024

    Standard health inspection

    20 findings

    The same visit included a complaint investigation.

    • 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.Level ENo actual harm, potential for moreCorrected Jul 20, 2024
    • 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.Level ENo actual harm, potential for moreCorrected Jul 20, 2024
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jul 20, 2024
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 20, 2024
    • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • 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.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • 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.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Jul 20, 2024
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jul 20, 2024

    Enforcement Action

    Civil money penalty, $8,827 imposed September 9, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 31, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  5. 2024

    Complaint investigation

    3 findings

    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 14, 2024
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 14, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 14, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  6. 2023

    Standard health inspection

    13 findings

    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Apr 3, 2023
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level FNo actual harm, potential for moreCorrected Apr 3, 2023
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Apr 3, 2023
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Apr 3, 2023
    • F886Perform COVID19 testing on residents and staff.Level FNo actual harm, potential for moreCorrected Apr 3, 2023
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Apr 3, 2023
    • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 3, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 3, 2023
    • F659Provide care by qualified persons according to each resident's written plan of care.Level DNo actual harm, potential for moreCorrected Apr 3, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 3, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 3, 2023
    • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Apr 3, 2023
    • 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.Level DNo actual harm, potential for moreCorrected Apr 3, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

03

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

  1. 1

    Accident Hazards and Supervision, Cited in Four Inspections

    Inspectors cited F689 in April 2024, May 2024, September 2024 and September 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F689 across all 6 inspections, oldest to newest
  2. 2

    Protection From Abuse and Neglect, Cited in Three Inspections

    Inspectors cited F600 in May 2024, September 2025 and June 2026. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F600 across all 6 inspections, oldest to newest
  3. 3

    Reporting Suspected Abuse, Cited in Three Inspections

    Inspectors cited F609 in April 2024, September 2025 and June 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F609 across all 6 inspections, oldest to newest
  4. 4

    Quality of Care, Cited in Three Inspections

    Inspectors cited F684 in February 2023, May 2024 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F684 across all 6 inspections, oldest to newest
  5. 5

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in February 2023, May 2024 and September 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F812 across all 6 inspections, oldest to newest
  6. 6

    Citation F552, Cited in Two Inspections

    Inspectors cited F552 in May 2024 and September 2025. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F552 across all 6 inspections, oldest to newest
  7. 7

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in April 2024 and June 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F610 across all 6 inspections, oldest to newest
  8. 8

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in February 2023 and May 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F657 across all 6 inspections, oldest to newest
  9. 9

    Pressure Injury Care, Cited in Two Inspections

    Inspectors cited F686 in February 2023 and May 2024. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F686 across all 6 inspections, oldest to newest
  10. 10

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in February 2023 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242526F880 across all 6 inspections, oldest to newest
04

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

  1. 01

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in four inspections, most seriously at level J.

  2. 02

    What happened after the abuse or neglect citation, and what changed in training or supervision?

    Protection From Abuse and Neglect: cited in three inspections, most seriously at level E.

  3. 03

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in three inspections, most seriously at level E.

  4. 04

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in three inspections, most seriously at level D.

  5. 05

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in three inspections, most seriously at level F.

  6. 06

    What changed after F552 was cited, and how do you check it now?

    Citation F552: cited in two inspections, most seriously at level D.

  7. 07

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in two inspections, most seriously at level E.

  8. 08

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level D.

  9. 09

    How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

    Pressure Injury Care: cited in two inspections, most seriously at level G.

  10. 10

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level F.

  11. 11

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

  12. 12

    What led to the 2024 fine, and has it been paid?

    An $8,827 civil money penalty was imposed September 9, 2024. CMS publishes the fine, not whether it has been paid.

05

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oregon state survey agency.

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Feb 25, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Apr 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection May 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Sep 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Sep 19, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Oregon state survey agency

    Inspection Jun 24, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Penalties, Provider Data Catalog

    Centers for Medicare & Medicaid Services

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗
  • Provider Information, Provider Data Catalog

    Centers for Medicare & Medicaid Services · 385138

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗

Coverage

Record windowFebruary 25, 2023 – October 1, 2026

  • CMS publishes about three inspection cycles; inspections before February 2023 are not in this release.
  • CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite
Allegations screened out by the state before an onsite visit are not published.
Complaint allegations
CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents
Self-reported incidents appear only if they led to an inspection.
Follow-up visits
CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections
Published by CMS separately and not included in this record yet.
Staffing levels and ownership history
Published by CMS separately and not included in this record.
Whether fines were paid
CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.