1876 Ne Highway 20, Bend, OR 97701 · Deschutes County · (541) 382-5531
74 certified beds, about 41 residents a day · For profit - Corporation · Medicare and Medicaid since 1978
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385138 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on September 19, 2025, inspectors cited 8 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 50 health citations since February 2023, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $8,827 in the last three years; the largest was $8,827, and the latest is dated September 9, 2024.
Nurses and nurse aides worked 4.89 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.94 of those hours.
50.8% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Regency Pacific Management, an affiliated group of 27 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 50 health citations on file.
Inspectors wroteBased on interviews and record review, it was determined the facility failed to protect the residents' right to be free from verbal abuse by another resident for 4 of 5 sampled residents (#s 15, 16, 18, and 19) reviewed for verbal abuse. This placed residents at risk for further abuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to report to the State Survey Agency an allegation of verbal abuse for 4 of 5 sampled residents (#s 15, 16, 18, and 19) reviewed for verbal abuse. This placed residents at risk for continued abuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to investigate allegations of verbal abuse for 4 of 5 sampled residents (#s 15, 16, 18, and 19) reviewed for verbal abuse. This placed residents at risk for further abuse.
Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure residents were free from misappropriation of property for 3 of 3 sampled residents (#s 8, 18, and 21) reviewed for misappropriation. This placed residents at risk for missed medications and an increase in pain.
Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure community resources were in place for a safe and orderly discharge for 1 of 3 sampled residents (#4) reviewed for discharge. This placed residents at risk for an unsafe discharge.
Inspectors wroteBased on observations, interview and record review it was determined the facility failed to maintain safe water temperatures for 1 of 2 halls ([NAME] Falls Hall). This placed residents at risk for burns.
Inspectors wroteBased on observation and interview the facility failed to ensure proper hand hygiene and sanitary surfaces for 1 of 1 kitchen. This placed residents at risk for cross-contamination.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow infection control standards for 2 of 2 sampled residents (#s 1 and 24) reviewed for hospice and transmission-based precautions. This placed residents at risk for exposure to, and contraction of, infectious diseases.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 2 of 5 sampled residents (#6 and 36) reviewed for medications and dementia. This placed residents at risk for being uniformed.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect the residents' right to be free from neglect and protect the residents' rights to be free from verbal and physical abuse by Staff 24 for 2 of 4 sampled residents (#s 47 and 51) reviewed for neglect and abuse. This placed residents at risk for abuse and neglect.
Inspectors wroteBased on interview and record review it was determined the facility failed to report allegations of neglect and abuse timely for 3 of 4 sampled residents (#s 21, 47, and 51) reviewed for abuse and neglect. This placed residents at risk for neglect and abuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital and notify the Ombudsman for 1 of 2 sampled residents (# 6) reviewed for hospitalization and discharge. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and failed to monitor a resident for a change of condition for 3 of 5 sampled residents (#s 2, 5, and 8) reviewed for medications. This placed residents at risk for unmet care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was safe from elopement for 1 of 1 sampled resident (#1) reviewed for elopement. This failure was determined to be an immediate jeopardy situation due to the facility failed to follow the Resident 1's care plan and provide adequate supervision, which resulted in Resident 1's elopement from the facility.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain comfortable temperature levels for 1 of 2 (Pine Meadow Hall) halls observed for environment. This placed residents at risk for uncomfortable temperatures.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide therapeutic diets to 3 of 4 (#s 2, 23, and 28) sampled residents reviewed for food. This placed residents at risk for unmet nutritional needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure meals were palatable, attractive, and at an appetizing temperature for 1 of 1 kitchen and 3 of 4 sampled residents (#s 9, 11 and 23) reviewed for food quality. This placed residents at risk for unmet nutritional needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure beard restraints were worn during meal preparation for 1 of 1 sampled kitchen reviewed for sanitary food practices. This placed residents at risk for contaminated food.
Inspectors wroteBased on interview, and record review it was determined the facility failed to obtain consent to administer medication for 1 of 5 (#16) sampled residents reviewed for unnecessary medications. This placed residents at risk for uninformed care.
Inspectors wroteBased on interview and record review it was determined the facility failed to evaluate a resident's choice for bathing for 1 of 1 sampled resident (#18) reviewed for choices. This place residents at risk for lack of honored choices.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure advance directive information was provided to residents for 3 of 4 sampled residents (#s 11, 34, and 40) reviewed for advance directives. This placed residents at risk for lack of end-of-life choices being honored.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide an Advanced Beneficiary Notice for 1 of 3 (#5) sampled residents reviewed for Beneficiary Notification. This placed residents at risk for financial loss.
Inspectors wroteBased on interview and record review it was the determined the facility failed to prevent abuse for 3 of 3 (#s 14, 21, and 31) sampled residents reviewed for abuse. This placed residents at risk for abuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to revise care plans for 2 of 5 sampled residents (#s 2 and 34) reviewed for unnecessary medications. This placed residents at risk for lack of appropriate care.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 2 of 2 sampled residents (#s 7 and 9) reviewed for accidents and hospice. This placed residents at risk for unmet care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to scheduled an audiology exam for 1 of 1 sampled resident (#22) reviewed for communication needs. This placed residents at risk for unmet needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess pressure wounds and follow physician orders for 2 of 3 sampled residents (#s 4 and 19) reviewed for pressure ulcers. This placed resident at risk for worsening wounds.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide adequate supervision for 1 of 2 sampled residents (#33) reviewed for accidents. This placed residents at risk for injury.
Inspectors wroteBased on interview and record review it was determine the facility failed to implement orders and consistently monitor a dialysis (a procedure to remove excess waste products and fluid from the blood) access site for 1 of 1 sampled resident (#2) reviewed for dialysis. This placed residents at risk for dialysis complications.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was assisted with discharge planning arrangements for 1 of 1 sampled resident (#11) reviewed for care planning. This placed residents at risk for increased anxiety.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure non-pharmacological interventions were provided prior to PRN antianxiety medication administration for 1 of 5 sampled residents (#37). This placed residents at risk for sedation.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure orders for a hypertensive medication were implemented for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for abnormal heart rhythms.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to honor resident food preferences for 2 of 4 (#s 22 and 28) sampled residents reviewed for food. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide immunizations to 1 of 5 sampled residents (#21) reviewed for immunizations. This placed residents at risk for infections.
Inspectors wroteBased on interview and record review it was determined the facility failed to report to the State Agency an unwitnessed fall with serious bodily injury for 1 of 3 sampled residents (#101) reviewed for accidents. This placed residents at risk for additional accidents and potential abuse. Findings Include: Resident 101 was admitted to the facility in 8/2023, with diagnoses including hip fracture, history of falls, and dementia with cognitive decline. An Incident Report dated 8/31/23 indicated a nurse was called to Resident 101's room because of a fall. The resident was found lying in bed with a skin tear above the left eye and another on the right elbow. There were no witnesses listed. The nurse found bruising and excess fluid when she assessed the elbow. The resident was sent out to the hospital. [...]
Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate an unwitnessed fall with a major injury and rule out potential abuse or neglect for 1 of 3 sampled residents (#101) reviewed for falls. This placed resident at risk for additional falls and potential abuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the environment was free of potential accident hazards for 1 of 3 sampled residents (#103) reviewed for accidents. This placed the residents at risk for potential accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders and provide care and services to promote the healing of pressure ulcers for 1 of 2 sampled residents (#1) reviewed for pressure ulcers. Resident 1 developing a facility acquired unstageable pressure ulcer.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure professional standards were followed related to proper infection control techniques for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination.
Inspectors wroteBased on observation, interview and record review the facility failed to utilize hygienic practices when handling food, ensure temperature logs were completed for the dishwasher and ensure a cleaning schedule was followed for 1 of 1 kitchen. This placed residents at risk for foodborne illness.
Inspectors wrote1. Based on observation, interview and record review it was determined the facility failed to follow proper infection control practices for 2 of 2 sampled residents (#s 1 and 19) reviewed for wound care and diabetic testing. This placed residents at risk for cross contamination.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure appropriate COVID-19 testing was conducted for staff during a COVID-19 outbreak for 1 of 1 facility reviewed for infection control. This place residents a risk for COVID-19 infections.
Inspectors wroteBased on observation and interview it was determined the facility failed to provide a safe, functional and sanitary environment for 1 of 1 laundry rooms reviewed for infection control. This placed residents at risk for contaminated laundry and staff at risk for injury.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident representatives were notified of a change of condition for 1 of 1 sampled resident (#9) reviewed for notification of change. This placed residents and resident representatives at risk for lack of information.
Inspectors wroteBased on interview and record review it was determined the facility failed to revise care plans related to fluid restrictions and medical devices for 2 of 2 sampled residents (#s 13 and 184) reviewed for dialysis and care planning. This placed residents at risk for lack of adequate care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure qualified staff assessed wounds for 2 of 2 LPNs reviewed for wound care. This placed residents at risk for receiving inadequate treatment.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#232) reviewed for ADLs. This placed resident at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain physician orders for 1 of 1 sampled resident (#233) reviewed for catheters. This placed residents at risk for unmet care needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure appropriate foot care was provided for residents with compromised mobility for 1 of 1 sampled resident (#2) reviewed for ADLs. This placed resident at risk for unmet foot care needs.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to ensure nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents for 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of proper treatment and care by competent staff.
18 fire safety citations on file: 3 on September 19, 2025, 9 on May 31, 2024, 6 on February 25, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| September 9, 2024 | Fine | $8,827 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.89 | 5.03 | 3.86 |
| Registered nurses | 0.94 | 0.72 | 0.69 |
| All nursing staff on weekends | 3.94 | 4.51 | 3.42 |
| Nurse aides | 3.09 | ||
| Licensed practical nurses | 0.86 | ||
| Nursing staff turnover (share who left in a year) | 50.8% | 47.4% | 45.8% |
| Registered nurse turnover | 27.3% | 51.6% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.56 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.27 on weekdays and 3.94 on weekends, 25% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.28 in April to June 2025 to 4.89 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.89 | 0.94 | 5.27 | 3.94 | 0.0% | 0 of 90 | 41 |
| Oct to Dec 2025 | 4.99 | 1.11 | 5.32 | 4.17 | 1.4% | 0 of 92 | 39 |
| Jul to Sep 2025 | 4.86 | 1.11 | 5.19 | 4.01 | 4.1% | 0 of 92 | 43 |
| Apr to Jun 2025 | 4.28 | 0.84 | 4.47 | 3.81 | 7.6% | 0 of 91 | 47 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Oregon, all employers | |||
| CNAs (nursing assistants) | $23.96 | $22.83 to $28.40 | 14,800 |
| LPNs and LVNs | $38.69 | $35.11 to $43.60 | 4,260 |
| Registered nurses | $62.02 | $51.55 to $64.63 | 39,730 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 20.8 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 8.0 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.7 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.9 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 10.9 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.5 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.8 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 27.7 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 5.6 | 16.1 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Pilot Butte Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (51.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
51.1% this home
No different from the national rate
US median of homes 51.5% · Oregon: 52 better, 3 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 137 eligible stays.
10.2% this home
No different from the national rate
US median of homes 10.7% · Oregon: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 137 eligible stays.
6.8% this home
No different from the national rate
US median of homes 7.1% · Oregon: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 80 eligible stays.
73.5% this home
Median of homes: Oregon59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 68 residents counted.
1.0% this home
Median of homes: Oregon0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 99 residents counted.
1.4% this home
Median of homes: Oregon2.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 99 residents counted.
98.0% this home
Median of homes: Oregon98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 50 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: BD BEND II LLC. CMS links this home to Regency Pacific Management, a group of 27 nursing homes averaging 3.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bd Facilities LLC | 5% or greater direct ownership interest | Organization | 100% | 04/01/2010 |
| Beddoe, Marvin | 5% or greater indirect ownership interest | Individual | 99% | 04/01/2017 |
| Beddoe, Sandra | Indirect ownership interest | Individual | 05/01/2017 | |
| Regency Pacific Management LLC | Operational/managerial control | Organization | 01/01/2010 | |
| Beddoe, Marvin | Operational/managerial control | Individual | 06/01/2016 | |
| Johnson, Sarah | Operational/managerial control | Individual | 09/05/2023 | |
| Rapp, Andrew | Operational/managerial control | Individual | 03/08/2016 | |
| Suarez, Yolanda | Operational/managerial control | Individual | 02/01/2026 | |
| Beddoe, Marvin | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 03/10/2026 | |
| Bd Facilities LLC | Adp of the SNF | Organization | 02/19/2026 | |
| Omnicare LLC | Adp of the SNF | Organization | 09/01/2013 | |
| Regency Pacific Management LLC | Adp of the SNF | Organization | 08/26/2025 | |
| Beddoe, Marvin | Adp of the SNF | Individual | 06/01/2016 | |
| Beddoe, Sandra | Adp of the SNF | Individual | 05/01/2017 | |
| Johnson, Sarah | Adp of the SNF | Individual | 09/05/2023 | |
| Rapp, Andrew | Adp of the SNF | Individual | 03/08/2016 | |
| Suarez, Yolanda | Adp of the SNF | Individual | 02/01/2026 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.