Health inspection·April 10, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor output of foley catheters (FC - a thin, flexible tube that drains urine from the bladder into a bag) per facility policy and physician orders for three of three sampled residents (Resident 1, 2, 3). This failure had the potential to endanger the residents and cause complications due to inaccuracies in fluid balance monitoring. Findings: A record review of facility policy Catheter – Care of dated 6/10/21 indicated Nursing staff will assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine. A record review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (here there's a blockage in the urinary tract, preventing the normal flow of urine), atrial fibrillation (a type of irregular heartbeat where the upper chambers of the heart beat out of sync and very rapidly), and metabolic encephalopathy (a brain dysfunction caused by problems with the body's metabolism or other systemic illnesses). A record review of facility physician orders dated 3/5/25 indicated staff were to assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output, every shift. A record review of Resident 1 ' s Intake and Output record dated 3/5/25 to 3/26/25 indicated no output from Resident 1 was documented. A record review of Resident 1 ' s Bladder Report dated 2/26/25 to 3/26/25 indicated no output from Resident 1 was documented. A record review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included retention of urine (the inability to completely empty the bladder, either suddenly (acute) or over time (chronic), metabolic encephalopathy, congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs), and benign prostatic hyperplasia (where the prostate gland grows larger than normal). Page 1 of 2 056258 056258 04/10/2025 River Valley Healthcare & Wellness Centre, LP 2490 Court Street Redding, CA 96001

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of facility physician orders dated 1/30/25 indicated staff were to assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output, every shift. A record review of Resident 3 ' s admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease causing restricted airflow and breathing problems), acute respiratory failure with hypoxia (the respiratory system cannot adequately oxygenate the blood, resulting in low blood oxygen levels), irritable bowel syndrome (IBS - a functional gastrointestinal (GI) disorder characterized by abdominal pain and changes in bowel habits, such as diarrhea, constipation, or both), and constipation (where bowel movements occur less than three times a week, and stools are hard, dry, or difficult to pass). A record review of facility physician orders dated 3/18/25 indicated staff were to assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output, every shift. During a concurrent interview with the Director of Nursing (DON) on 4/10/25 at 12:01 pm, DON confirmed there was no output documented for Resident 2 and Resident 3 on their facility Intake and Output reports and Bladder reports from January 2025 to April 2025. DON also confirmed physician orders for Resident 1, 2, and 3 ordered output from FC bags to be documented. DON confirmed facility policy indicated staff was supposed to document FC bag output. DON confirmed FC bag output was not documented for Resident 1, 2 and 3, per policy. DON stated facility catheter policy and physician orders were not followed, and should have been. 056258 Page 2 of 2