Roosevelt Rehab: No Care Plan for Catheter - PA
The resident, identified as R1 in inspection records, was admitted to the Bustleton Avenue facility in August 2024 with multiple urinary complications including chronic kidney disease, urinary tract infection, prostatic hyperplasia with lower urinary tract symptoms, urinary urgency, and urinary retention.
On August 8, 2025, medical notes documented that a "new Foley catheter 16Fr/10mL" was placed during a urology appointment. The entry marked it as "Day 1/3," indicating the start of a three-day period following the catheter insertion.
When inspectors reviewed the resident's comprehensive care plan dated May 20, 2025, they found no provisions for catheter care. The facility's own policy, updated in March 2022, requires "a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs" for each resident.
Assistant Director of Nursing Employee E3 confirmed the oversight during an interview with inspectors on August 11 at 11:06 a.m. The administrator acknowledged that no comprehensive care plan had been developed for the urinary catheter.
The absence of catheter care planning represents a significant gap in medical oversight. Urinary catheters require specific protocols for insertion site monitoring, infection prevention, drainage bag management, and regular assessment for continued medical necessity.
Roosevelt Rehabilitation operates as a 240-bed skilled nursing facility in Northeast Philadelphia. The facility has faced previous regulatory scrutiny, though this complaint-driven inspection focused specifically on care planning deficiencies.
Federal nursing home regulations mandate that facilities develop individualized care plans addressing all aspects of resident health and daily living needs. These plans must include specific, measurable goals and timelines for achieving desired outcomes.
The inspection finding carries a "minimal harm" designation, meaning the deficiency had limited impact on resident safety but represented a failure to meet federal care standards. Inspectors classified the violation as affecting "few" residents, though they reviewed records for nine residents total during the complaint investigation.
Catheter-associated complications can include urinary tract infections, bladder stones, blood infections, kidney damage, and urethral injury. Proper care planning typically addresses positioning, securing methods, cleaning protocols, and monitoring for signs of infection or mechanical problems.
The resident's complex urinary conditions made comprehensive care planning particularly important. Prostatic hyperplasia with lower urinary tract symptoms can complicate catheter management, requiring specialized approaches to prevent complications and optimize comfort.
State regulations under 28 Pa Code 211.10(c) and 211.12(d)(5) govern resident care policies and nursing services in Pennsylvania long-term care facilities. The violations occurred nearly one year after the resident's initial admission, suggesting ongoing gaps in care plan updates and medical device management.
Roosevelt Rehabilitation must submit a plan of correction addressing how staff will ensure comprehensive care plans include all medical devices and treatments. The facility has 14 days from receiving the inspection report to make the corrected documents available to regulators.
The inspection report notes that deficiency findings become publicly disclosable 14 days after the facility receives the documentation. Roosevelt Rehabilitation must demonstrate continued compliance with federal participation requirements to maintain Medicare and Medicaid certification.
No additional details about the resident's condition or outcomes were included in the inspection narrative. The complaint-driven investigation suggests concerns about care quality prompted the August review, though the specific nature of the original complaint remains undocumented in available records.
The catheter care planning failure occurred despite the facility having established policies requiring comprehensive, person-centered care plans with measurable objectives. The gap between written policy and actual implementation represents the type of oversight that federal inspectors target during routine and complaint-driven facility reviews.
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: June 20, 2026 · Our methodology
ROOSEVELT REHABILITATION AND HEALTHCARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on August 11, 2025.
On August 8, 2025, medical notes documented that a "new Foley catheter 16Fr/10mL" was placed during a urology appointment.
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.