Roosevelt Rehab: Catheter Order Missing, No Supervision - PA
It was 2:02 p.m. on August 11, 2025. Resident R1, a man with chronic kidney disease, urinary retention, and a freshly placed urinary catheter, was alone. His physician's order required 1:1 staff supervision every shift, meaning someone was supposed to be with him at all times. Nobody was.
When the inspector flagged the absence to the licensed nurse assigned to Resident R1, the nurse called the aide. Employee E7 came on the line and confirmed she had been assigned as his 1:1 supervisor. She said she had stepped away from his room for approximately five minutes.
Five minutes is not nothing when a supervision order exists for a reason.
The catheter itself carried its own paper trail problem. Resident R1 had been admitted to Roosevelt Rehabilitation and Healthcare Center in August 2024 with a cluster of urological diagnoses, including urinary tract infections, prostatic hyperplasia, urinary urgency, and urinary retention. On August 8, 2025, a nursing note recorded that he had received a new Foley catheter, 16 French, placed that morning at a urology appointment.
A Foley catheter is an indwelling urinary catheter, a tube threaded through the urethra into the bladder to drain urine continuously. For a resident already prone to urinary tract infections, proper documentation and physician oversight of that catheter matters.
There was no physician order for it. Inspectors reviewed Resident R1's physician orders and found nothing authorizing the catheter. The order had been missing since at least August 7, 2025, the day before the nursing note recorded its placement.
At 11:06 a.m. on August 11, the Unit Manager and the Assistant Director of Nursing, Employee E3, told inspectors that Resident R1 currently had a Foley catheter in place and was out of the facility at a doctor's appointment. Employee E3 produced a hard copy of the urology consultation confirming the catheter. What she could not produce was a physician order in the clinical record.
The facility's own catheter care policy, last revised in August 2022, spells out what should be documented every time catheter care is given: the date and time, the name of the person providing care, the character of the urine, any problems at the catheter-urethral junction, how the resident tolerated the procedure, and whether the resident refused. None of that documentation is meaningful if the catheter's existence isn't formally authorized in the medical record to begin with.
By 12:30 p.m., the Administrator and Director of Nursing sat down with inspectors and confirmed what the record already showed. The facility had failed to obtain a physician order for Resident R1's urinary Foley catheter.
The inspection, conducted as a complaint survey, cited the facility under F0684, which covers the requirement that residents receive treatment and care in accordance with professional standards of practice. Inspectors found the violations affected few residents, and the level of harm was classified as minimal harm or potential for actual harm, the lowest tier on the federal scale.
That classification reflects regulatory language, not necessarily lived experience. Resident R1 had a catheter with no formal order governing its care in a facility setting, and when an inspector came to check on him, the person supposed to be watching him was somewhere else.
Resident R1 was in his room when inspectors returned at 2:02 p.m., back from his earlier appointment, catheter in place. He confirmed he had it. The 1:1 aide was not there to confirm anything.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roosevelt Rehabilitation and Healthcare Center from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on August 11, 2025.
Resident R1, a man with chronic kidney disease, urinary retention, and a freshly placed urinary catheter, was alone.
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.