JL
Joanna Larsen
May 11, 2026
While the caregivers at Pilot Butte Rehabilitation were kind and clearly worked hard, our overall experience at the facility was unfortunately far below expectations.
From the very beginning, the priorities felt misplaced. When our 86-year-old mother, who suffers from Alzheimer’s disease, arrived at Pilot Butte Rehabilitation after breaking her hip, the staff seemed more focused on inventorying her belongings than ensuring she was comfortable and settled for recovery. This set the tone for the rest of her stay.
dThe facility itself appeared to be in poor condition. Her room had peeling paint and stains on the ceiling, and the bathrooms were clearly not ADA-compliant. In one of the rooms she stayed in, there was not even a bathroom door, making privacy extremely difficult. The bed sheets were also worn, with small holes throughout, which staff attributed to excessive bleaching.
Communication between staff members and across shifts was inconsistent. Important information was often not passed along, and we frequently had to repeat requests or correct misunderstandings. For example, despite our clearly requesting that Oxycodone only be administered if our mother’s pain became severe, it continued to be given even after she had been off the medication for more than five days. Because of her dementia, she was not able to make an informed decision regarding this medication and would simply take what was provided if family members were not present to intervene.
One of the most distressing incidents involved the facility making a report to social services based on incorrect information. As a result, our mother was contacted and told that “she has rights” and that her daughters should not force her into lockdown memory care. This was completely untrue, as we had no plans to move her into memory care. The confusion and fear this caused our family was significant and entirely avoidable.
Throughout her more than two-week stay, it became clear that without constant family presence, her care and progress would likely have suffered further. Processes appeared disorganized, and critical details were often overlooked.
Another alarming incident involved a patient who was temporarily lost within the facility. Staff reacted with visible panic, with many running out of the building and leaving other patients unattended. It was chaotic and deeply concerning to witness.
After discharge, we encountered yet another frustrating issue. It took over a week for the facility to provide a physical therapy referral, despite multiple calls and follow-up emails from both our family and the recommended home health agency. This delay created unnecessary stress and disrupted what should have been a smooth continuation of her care.
Before my mother was admitted, I had read reviews that raised concerns, but given the circumstances following her hospital stay, this facility was our only viable option. Unfortunately, our experience reflected many of those same issues. While the caregivers deserve credit for their effort and kindness, the overall management, communication, and facility conditions made this an extremely difficult and, at times, distressing experience.