Skip to main content

Inspection visit

Health inspection

RIVER VALLEY HEALTHCARE & WELLNESS CENTRE, LPCMS #0562581 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, record review, and policy review, the facility failed to manage urinary retention (the inability to empty the bladder of urine) for one of four residents sampled (Resident 1) when Resident 1 did not urinate for over 14 hours, which can be a life-threatening medical emergency.This failure resulted in delayed treatment of Resident 1's urinary retention.Findings:Review of, National Institute of Health (a nationally recognized professional resource) webpage titled, Definitions & Facts of Urinary Retention dated December 2019 indicated that acute (sudden) urinary retention (the inability to empty the bladder of urine) can be life-threatening.Review of, National Institute of Health (a nationally recognized professional resource) webpage titled, Treatment of Urinary Retention dated December 2019 indicated that the treatment for acute urinary retention is to drain the bladder using a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine also known as a Foley Catheter).Review of a facility policy titled, Catheter-Intermittent (a hollow tube inserted into the bladder to drain urine from the bladder and immediately be removed and is often used to manage urinary retention) dated April 15, 2021, indicated IV. Intermittent catheterization will be used when medically necessary.Review of Resident 1's medical record indicated that he was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease (the kidneys are damaged and cannot filter blood the way they should).Review of Resident 1's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) dated 12/8/25, and completed by the Social Services Director (SSD) indicated that Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 indicating he could make his own decisions.Review of Resident 1's record titled, Bladder Report dated 12/8/25 indicated that Resident 1's last documented urination at the facility was on 12/8/25 at 11:32 pm, more than 14 hours before the facility sent him to the acute care hospital (a healthcare facility where patients are treated for brief but severe episodes of illness or injury).Review of Resident 1's record titled, SNF/NF to Hospital Transfer Form (a form used to help convey information to the acute care hospital about why the resident was transferred to the acute care hospital) (SNF a skilled nursing facility - are places for people to live temporarily while they are getting rehabilitation and medical treatments after hospitalization for an illness or injury), dated 12/9/25 at 2:08 pm, completed by Licensed Nurse (LN A) indicated that Resident 1 was transferred to the acute care hospital. There was no mention in this form that Resident 1 had not urinated for over 14 hours.Review of Resident 1's record titled, Communication-with Physician dated 12/9/25 at 2:39 pm written by LN A, indicated .Resident has had no urine output since yesterday.Review of Resident 1's acute care hospital emergency department report dated 12/9/25 at 3:49 pm, indicated that Resident 1 had a urinary catheter inserted and the amount of urine drained from his bladder was 2 liters (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056258 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Valley Healthcare & Wellness Centre, LP 2490 Court Street Redding, CA 96001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (2,000 milliliters), which is equal to almost 8 and a half cups.Review of the, National Library of Medicine (a nationally recognized resource for healthcare providers) webpage titled Bladder Catheterization dated August 8, 2023, indicated that The capacity of the bladder can vary between 350 milliliters - 500 milliliters which is equal to about 1.5 cups to 2 cups.During an interview on 2/10/26 at 3:35 pm, with the Director of Nursing (DON), the DON acknowledged there was no documentation of Resident 1 urinating for over 14 hours, from 12/8/25 at 11:32 pm, till 12/9/25 at 2:08 pm, when he was sent to the acute care hospital. The DON indicated that LN A could have gotten a physician's order (written instructions from a doctor detailing specific treatments, medications, or tests for a patient) for an intermittent catheter and drained Resident 1's bladder but she did not realize Resident 1 had not urinated until later.During an interview on 2/10/26 at 4:35 pm with the DON, the DON indicated that Resident 1 not urinating happened over two shifts and that the nurse on the night shift did not have 8 or more hours of Resident 1 not urinating to report to LN A at the shift change so that LN A would be aware. The DON indicated that LN A did not recognize that Resident 1 had not urinated, until almost 8 hours into her shift.During an interview on 2/11/26 at 2:20 pm, with the DON, the DON indicated that the facility does not have a urinary retention policy (a written document used in healthcare facilities that guide how healthcare is delivered, specifically in this case for urinary retention). Event ID: Facility ID: 056258 If continuation sheet Page 2 of 2

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Back to top

Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

FAQ · About this visit

Common questions about this visit

What happened during the February 11, 2026 survey of RIVER VALLEY HEALTHCARE & WELLNESS CENTRE, LP?

This was a inspection survey of RIVER VALLEY HEALTHCARE & WELLNESS CENTRE, LP on February 11, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at RIVER VALLEY HEALTHCARE & WELLNESS CENTRE, LP on February 11, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

Share this reportEmail

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.