Inspection Reports for Pilot Butte Rehabilitation Center

OR, 97701

Back to Facility Profile

Deficiencies (last 4 years)

Deficiencies (over 4 years) 17.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

161% worse than Oregon average
Oregon average: 6.7 deficiencies/year

Deficiencies per year

24 18 12 6 0
2021
2023
2024
2025
Inspection Report Capacity: 74 Deficiencies: 1 Oct 31, 2025
Visit Reason
No deficiencies identified during this Re-Licensure survey. Initial comments noted with no corrections.
Findings
No deficiencies identified during this Re-Licensure survey. Initial comments noted with no corrections.
Deficiencies (1)
Description
M0000 - Initial Comments
Inspection Report Complaint Investigation Capacity: 74 Deficiencies: 2 Oct 29, 2025
Visit Reason
No deficiencies identified during this Complaint and Re-Licensure survey. Initial comments noted with no corrections.
Findings
No deficiencies identified during this Complaint and Re-Licensure survey. Initial comments noted with no corrections.
Deficiencies (2)
Description
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report Complaint Investigation Capacity: 74 Deficiencies: 13 Sep 19, 2025
Visit Reason
Multiple deficiencies identified including failure to obtain informed consent for medications, abuse and neglect incidents, failure to report alleged violations timely, discharge process issues, quality of care concerns, accident hazards, food sanitation, infection prevention and control, and nursing services documentation. Most deficiencies were corrected by the second visit on 11/18/2025.
Findings
Multiple deficiencies identified including failure to obtain informed consent for medications, abuse and neglect incidents, failure to report alleged violations timely, discharge process issues, quality of care concerns, accident hazards, food sanitation, infection prevention and control, and nursing services documentation. Most deficiencies were corrected by the second visit on 11/18/2025.
Deficiencies (13)
Description
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
F0628 - Discharge Process
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M0180 - Nursing Services: Daily Staff Public Posting
M0182 - Nursing Services:Minimum Licensed Nurse Staff
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report Complaint Investigation Capacity: 74 Deficiencies: 2 Oct 16, 2024
Visit Reason
No deficiencies identified during this Complaint, Licensure Complaint, State Licensure survey. Initial comments noted with no corrections.
Findings
No deficiencies identified during this Complaint, Licensure Complaint, State Licensure survey. Initial comments noted with no corrections.
Deficiencies (2)
Description
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report Complaint Investigation Capacity: 74 Deficiencies: 4 Sep 9, 2024
Visit Reason
Deficiencies related to failure to prevent elopement, inadequate supervision, failure to follow care plans, and failure to report timely. Immediate jeopardy was identified and removed during the survey. Multiple deficiencies remained uncorrected at revisit.
Findings
Deficiencies related to failure to prevent elopement, inadequate supervision, failure to follow care plans, and failure to report timely. Immediate jeopardy was identified and removed during the survey. Multiple deficiencies remained uncorrected at revisit.
Deficiencies (4)
Description
F0000 - INITIAL COMMENTS
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report Complaint Investigation Capacity: 74 Deficiencies: 21 May 31, 2024
Visit Reason
Numerous deficiencies identified including failure to obtain informed consent for medications, abuse prevention, care planning, quality of care, dietary services, infection control, and nursing services. Some deficiencies were corrected by revisit, others remained uncorrected.
Findings
Numerous deficiencies identified including failure to obtain informed consent for medications, abuse prevention, care planning, quality of care, dietary services, infection control, and nursing services. Some deficiencies were corrected by revisit, others remained uncorrected.
Deficiencies (21)
Description
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0561 - Self-Determination
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0582 - Medicaid/Medicare Coverage/Liability Notice
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0600 - Free from Abuse and Neglect
F0657 - Care Plan Timing and Revision
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0698 - Dialysis
F0745 - Provision of Medically Related Social Service
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0760 - Residents are Free of Significant Med Errors
F0803 - Menus Meet Resident Nds/Prep in Adv/Followed
F0804 - Nutritive Value/Appear, Palatable/Prefer Temp
F0806 - Resident Allergies, Preferences, Substitutes
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0883 - Influenza and Pneumococcal Immunizations
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report Complaint Investigation Capacity: 74 Deficiencies: 7 Apr 17, 2024
Visit Reason
Deficiencies related to failure to report unwitnessed fall with serious injury timely, failure to investigate thoroughly, failure to ensure accident hazard free environment, minimum CNA staffing not met, and other nursing service issues. Some deficiencies corrected by revisit, others remained uncorrected.
Findings
Deficiencies related to failure to report unwitnessed fall with serious injury timely, failure to investigate thoroughly, failure to ensure accident hazard free environment, minimum CNA staffing not met, and other nursing service issues. Some deficiencies corrected by revisit, others remained uncorrected.
Deficiencies (7)
Description
F0000 - INITIAL COMMENTS
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report Complaint Investigation Capacity: 74 Deficiencies: 16 Feb 25, 2023
Visit Reason
Multiple deficiencies identified including failure to notify resident representatives of changes, failure to revise care plans timely, failure to follow professional standards for infection control and wound care, failure to provide adequate ADL care, failure to ensure competent nursing staff, and failure to maintain sanitary food preparation. Some deficiencies were corrected by revisit, others remained uncorrected.
Findings
Multiple deficiencies identified including failure to notify resident representatives of changes, failure to revise care plans timely, failure to follow professional standards for infection control and wound care, failure to provide adequate ADL care, failure to ensure competent nursing staff, and failure to maintain sanitary food preparation. Some deficiencies were corrected by revisit, others remained uncorrected.
Deficiencies (16)
Description
F0000 - INITIAL COMMENTS
F0580 - Notify of Changes (Injury/Decline/Room, etc.)
F0657 - Care Plan Timing and Revision
F0658 - Services Provided Meet Professional Standards
F0659 - Qualified Persons
F0677 - ADL Care Provided for Dependent Residents
F0684 - Quality of Care
F0687 - Foot Care
F0726 - Competent Nursing Staff
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0880 - Infection Prevention & Control
F0886 - COVID-19 Testing-Residents & Staff
F0921 - Safe/Functional/Sanitary/Comfortable Environ
M0000 - Initial Comments
M0143 - Employees: Criminal Record Checks
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report Annual Inspection Capacity: 74 Deficiencies: 1 Sep 17, 2021
Visit Reason
No deficiencies identified during this State Licensure survey. Initial comments noted with no corrections.
Findings
No deficiencies identified during this State Licensure survey. Initial comments noted with no corrections.
Deficiencies (1)
Description
M0000 - Initial Comments
Inspection Report Capacity: 74 Deficiencies: 3 Mar 2, 2021
Visit Reason
No deficiencies identified during this Focused Infection Control and other surveys. Initial comments noted with no corrections.
Findings
No deficiencies identified during this Focused Infection Control and other surveys. Initial comments noted with no corrections.
Deficiencies (3)
Description
E0000 - Initial Comments
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Loading inspection reports...