Pilot Butte Rehabilitation Center: PPE Violation - OR
The September 18 incident unfolded at 2:01 in the afternoon. A hospice registered nurse, identified in inspection records as Staff 18, was overheard telling a resident that her catheter was leaking and that she was going to turn on the light to change it. Inspectors observed Staff 18 wearing gloves. No gown.
At 2:19 PM, Staff 18 removed her gloves. Still no gown.
When inspectors asked her about it afterward, Staff 18 confirmed she had changed the resident's catheter wearing only gloves. She acknowledged a gown should have been worn during catheter care.
That was the entirety of the defense: yes, I know, I should have.
The facility's own infection control expectations, described by the Regional Director of Clinical Operations the following morning, required staff to wear both gloves and a gown for high-contact resident care, a category that explicitly includes catheter care, bathing, transferring residents, changing linens, assisting with toileting, and providing hygiene. The Regional Director, identified as Staff 11, confirmed those expectations to inspectors at 7:14 AM on September 19, the same morning the complaint inspection was completed.
Federal inspectors cited the facility under F0880, the infection prevention and control tag, finding the lapse reflected a pattern affecting more than one resident.
The violation was rated at the lower end of the federal harm scale, meaning inspectors found minimal harm or potential for actual harm rather than documented injury. That distinction matters in how regulators categorize the citation, but it does not change what happened in that room: a nurse performing an invasive procedure on a person who was on hospice, already at the end of life, without the protective equipment her own facility required her to use.
Catheter care carries infection risk in both directions. Gowns protect the resident's environment from contaminants a caregiver may carry, and they protect the caregiver from exposure to bodily fluids. Skipping a gown during a catheter change, particularly one involving a leaking catheter, creates a direct pathway for contamination.
The inspection was triggered by a complaint, not a routine survey. That means someone, a resident, a family member, or a staff member, flagged a concern serious enough to prompt regulators to send an inspector to Pilot Butte. The records do not identify who filed the complaint or what specifically prompted it, but the catheter incident was what inspectors documented when they arrived and began observing care.
Pilot Butte Rehabilitation Center is a skilled nursing facility in Bend, a city in central Oregon that has grown rapidly over the past decade and serves a significant elderly and post-acute care population. Residents receiving hospice services within a skilled nursing facility are among the most medically fragile people in any care setting. They are not there to recover. They are there because they need around-the-clock support at the end of their lives, and their immune systems often reflect that reality.
The Regional Director of Clinical Operations confirmed the next morning that the expectation was clear. Staff were supposed to follow the evidence-based practice sign and policy for PPE. The sign was presumably posted. The policy existed. Staff 18 knew what it said.
She changed the catheter anyway, in gloves only, and the inspection report does not indicate anyone intervened in the moment or caught it before inspectors did.
What the record does not contain is any indication of what happened to the resident after the catheter was changed, whether the leak was resolved, whether she experienced any complication, or what her condition was in the days that followed. She was on hospice. That is all the report says about her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pilot Butte Rehabilitation Center from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 15, 2026 · Our methodology
PILOT BUTTE REHABILITATION CENTER in BEND, OR was cited for violations during a health inspection on September 19, 2025.
The September 18 incident unfolded at 2:01 in the afternoon.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.