Pilot Butte Rehabilitation Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 33 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (2/5 stars)
- High staff turnover (55%)
- High RN turnover (57%)
Below average in OR · Meets national RN staffing standard · Above recommended total nurse staffing · Below chain average · $8,827 in fines · Abuse citation
What this means for your family
While the physical therapy department is frequently praised for helping patients recover mobility, the facility suffers from significant, recurring reports of neglect and poor administrative communication. If you choose this facility, ensure you have a plan for frequent, in-person visits to monitor your loved one's hygiene and care, as response times and staff attentiveness appear highly inconsistent.
Google Reviews
Google Reviews
33 reviews on Google“Pilot Butte Rehabilitation Center receives highly polarized feedback, with recent reviews showing a sharp divide between praise for the physical therapy team and severe concerns regarding basic patient care and administrative responsiveness. While some families report successful rehab outcomes and attentive staff, others describe alarming incidents of neglect, poor communication, and unprofessional management. The facility's reputation appears volatile, with significant complaints regarding the consistency of care and the quality of the environment.”
Quality Themes
Tap a score for detailsStrengths
- Highly effective physical therapy team
- Some staff members described as caring and professional
- Successful rehabilitation outcomes for some patients
Concerns
- Neglect and poor hygiene (e.g., not changing patients, failure to hydrate) (mentioned by 4 reviewers)
- Poor communication and difficulty reaching staff by phone (mentioned by 3 reviewers)
- Unprofessional or rude administrative/management staff (mentioned by 4 reviewers)
- Slow response times to call buttons and patient needs (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 35 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1We've heard great things about your physical therapy team; could you tell us more about how the rehab process works for new residents?
- 2How does the nursing staff ensure that residents' personal hygiene and hydration needs are met consistently throughout the day?
- 3What is the protocol for responding to call buttons, and how do you ensure staff are available when a resident needs immediate assistance?
- 4Could you describe the dining experience, specifically how meal times are managed and how you ensure food quality and variety?
- 5How does the administration maintain clear and frequent communication with families, especially if we have questions or need an update?
- 6What kind of daily activities or social programs are available to keep residents engaged and active?
Personalized based on this facility's data
Key Review Excerpts
“The Rehab team seems good. The nurses and CNA's very dutiful but overwhelmed. But there is a clear failure on the part of their administration and their physicians.”
“I was surprised to see so many workers around interacting with patients every time I came in. I am pleasantly surprised that we had such good communication from staff, when our dad was there.”
“I watched my dad go into rehab by stretcher and by the time he was done, he WALKED out the front door.”
Staffing
Staffing Hours
per resident/day · Medicare 2026This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
5
measures
6
measures
6
measures
Residents vaccinated for the flu
Residents whose walking got worse
Residents needing more daily help over time
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents with a long-term catheter
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Pilot Butte has concerning patterns with multiple families filing complaints, particularly about resident protection from abuse and neglect, plus accident prevention failures. The facility shows recurring issues across safety supervision, infection control, and food service that persist across multiple surveys from 2023-2024. While all deficiencies show correction dates, the repeated problems in critical care areas and complaint-driven investigations suggest ongoing operational challenges families should carefully consider.
Sep 19, 2025Routine8
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Sep 19, 2025Complaint3
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Sep 9, 2024Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
May 31, 2024Routine28
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
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.
Nutrition and Dietary Deficiencies
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
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Egress Deficiencies
Meet other general requirements.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies
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
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Pharmacy Service Deficiencies
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
Ensure that residents are free from significant medication errors.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
May 31, 2024Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Apr 17, 2024Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Federal Penalties
Fine
Sep 9, 2024
$8,827
Ownership & Operations
Who Operates This Facility
Pilot Butte Rehabilitation Center
for profit
Chain Affiliation
Regency Pacific Management
27 facilities nationwide
Chain avg rating: 3.6/5 · Rank 25 of 27
Ownership & Management
Owners
Bd Facilities LLC
Owner · Organization
Beddoe, Marvin
Owner (parent company)
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
33 reviews from families & visitors
Official Website
Visit regency-pacific.com
Medicare data downloads
Original nursing home datasets
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