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