All citations for Pilot Butte Rehabilitation Center

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Pilot Butte Rehabilitation Center

Last standard health inspection on record

September 19, 2025

Showing 1 to 25 of 30 citations

  1. Immediate jeopardy to resident health or safety

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of September 9, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (September 10, 2024).

  2. No harm, with potential for more than minimal harm

    Address subsistence needs for staff and patients.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0015, Emergency Preparedness Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 19, 2024).

  3. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 19, 2024).

  4. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 19, 2024).

  5. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 19, 2024).

  6. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 19, 2024).

  7. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  8. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0803, Nutrition and Dietary Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  9. No harm, with potential for more than minimal harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0804, Nutrition and Dietary Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  10. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  11. No harm, with potential for more than minimal harm

    Meet other general requirements.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0200, Egress Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 19, 2024).

  12. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 19, 2024).

  13. No harm, with potential for more than minimal harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0552, Resident Rights Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  14. No harm, with potential for more than minimal harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0561, Resident Rights Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  15. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0578, Resident Rights Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  16. No harm, with potential for more than minimal harm

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0582, Resident Rights Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  17. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 31, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  18. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  19. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  20. No harm, with potential for more than minimal harm

    Assist a resident in gaining access to vision and hearing services.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0685, Quality of Life and Care Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  21. No harm, with potential for more than minimal harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  22. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  23. No harm, with potential for more than minimal harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0698, Quality of Life and Care Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  24. No harm, with potential for more than minimal harm

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0745, Quality of Life and Care Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

  25. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0758, Pharmacy Service Deficiencies. Inspection of May 31, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 20, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.