Fairview Rehab: Catheter Bag Left Unsanitary - PA
A federal inspection at Fairview Rehab and Care Center on August 28, 2025, found that a resident's urinary catheter leg bag had been left on the sink in the resident's room in an unsanitary condition. The unit manager confirmed it on the spot. There was no dispute about what inspectors saw.
The resident, identified only as Resident R1 to protect confidentiality, had been admitted to the facility with a stage 4 pressure ulcer at the sacral region, the kind that reaches through the full thickness of skin and into the tissue beneath. R1 also came in with a urinary tract infection and klebsiella pneumoniae, a bacterium that lives in the human intestine and causes urinary infections, pneumonia, and bloodstream infections. This was not a resident with a straightforward medical picture. This was someone already fighting infections on multiple fronts.
A physician order from May 8, 2025, documented a suprapubic urinary catheter, placed because of obstructive and reflux uropathy, a blockage of the urinary tract. A suprapubic catheter is inserted directly through the abdomen into the bladder. It requires careful, consistent hygiene. The leg bag attached to it collects urine and, if left in unsanitary conditions, becomes a direct pathway for bacteria to travel back into an already compromised body.
Inspectors spoke with R1 at 10:38 in the morning. The bag was on the sink. Sixty-four minutes later, at 11:42 a.m., the unit manager, identified in the report as Employee E4, confirmed exactly what inspectors had observed. The resident had an unsanitary catheter leg bag lying above the sink.
That confirmation matters. This was not a finding the facility contested, not a disputed observation requiring follow-up interviews and documentation review. A manager responsible for the unit looked at the situation and agreed it was exactly what the inspection report said it was.
The violation was cited under F0690, which covers catheter care and the prevention of urinary tract infections. The level of harm was recorded as minimal harm or potential for actual harm. One resident was affected, the one resident reviewed.
"Minimal harm or potential for actual harm" is the language regulators use. What it describes, in this room, for this particular resident, is something more specific: a person admitted with an active urinary tract infection and klebsiella pneumoniae, dependent on a catheter threaded through their abdomen, with the urine collection bag sitting on a shared bathroom surface in conditions the facility's own unit manager called unsanitary.
Klebsiella pneumoniae is not a routine infection. It is resistant to many antibiotics. In people with weakened immune systems, or those already carrying other serious wounds, it can move from the urinary tract into the bloodstream. A stage 4 sacral pressure ulcer, which R1 also had, is itself a site of serious infection risk. These conditions do not exist in isolation from each other.
The inspection report does not say how long the bag had been on the sink. It does not say whether staff had been in the room that morning before inspectors arrived, or whether anyone had noticed the bag and left it anyway. It does not say whether R1 had raised the issue with staff or had grown accustomed to it.
What it says is that when federal inspectors walked into that room, the bag was there. And when they asked the unit manager about it an hour later, she said yes, that's what it was.
Fairview Rehab and Care Center operates under Pennsylvania's nursing home regulations, which require sanitary catheter care and hold facility management accountable for nursing service standards. The inspection was conducted as a complaint survey, meaning someone had raised a concern before inspectors arrived.
R1 came to Fairview already sick, already infected, already carrying a bacterium that clinicians treat carefully precisely because of how quickly it can escalate. The catheter keeping that resident's urinary tract functioning sat connected to a bag that had been left on a sink.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairview Rehab and Care Center from 2025-08-28 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 29, 2026 · Our methodology
FAIRVIEW REHAB AND CARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on August 28, 2025.
The unit manager confirmed it on the spot.
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.