Health inspection·February 11, 2026

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 Page 1 of 2 056258 056258 02/11/2026 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 - Few (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). 056258 Page 2 of 2