Compiled from official CMS federal data
PILOT BUTTE REHABILITATION CENTER, BEND, OR — Violations & Inspection Reports
Does PILOT BUTTE REHABILITATION CENTER have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), PILOT BUTTE REHABILITATION CENTER (CCN 385138), in BEND, OR, has federal inspection findings. CMS currently displays its federal abuse icon for this facility — a flag CMS assigns under its own published methodology for abuse-related citations (deficiency tag F600 and related).
In its current inspection cycle, CMS cited the facility for 8 deficiencies; the most severe is rated E — which CMS classifies as "potential for harm," a level below actual harm (risk, but no harm confirmed). The latest standard health inspection on file is dated 2025-09-19. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $8,827 in civil money penalties on file against the facility. The record also includes 5 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Sep 2025). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 5 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Sep 2025.
- 4 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Sep 2025.
- 2 pressure-ulcer care citations (F686) — the consumer term is "bedsores"; most recent May 2024.
- 8 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
CMS displays its federal abuse icon on this facility's official record.
Below is this facility's federal inspection record as on file with CMS.
Federal abuse icon on file
CMS displays this icon for facilities it has cited for resident abuse under its own published methodology — the government's own flag, restated here.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$8,827
Have a lawyer review this record →
About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
42 more citations on file — Abuse & neglect 5 · Accidents & supervision 2 · Pressure ulcers 1 · Medication & pharmacy 2 · Resident rights 7 · Other citations 22 (expand)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Ensure that residents are fully informed and understand their health status, care and treatments.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that residents are free from significant medication errors.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that residents are fully informed and understand their health status, care and treatments.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Assist a resident in gaining access to vision and hearing services.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Ensure services provided by the nursing facility meet professional standards of quality.
Perform COVID19 testing on residents and staff.
Provide and implement an infection prevention and control program.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Provide care by qualified persons according to each resident's written plan of care.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide appropriate foot care.
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.
Overall CMS star rating
This facility: 2 · CMS state average: 3.1
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
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Federal record
PILOT BUTTE REHABILITATION CENTER — Federal Record
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SECTION 7 — CASE CONTEXT
Add what you saw at PILOT BUTTE REHABILITATION CENTER to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?