Umpqua Valley Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Umpqua Valley Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 13, 2022

  Based on interview and record review it was determined the facility failed to provide appropriate services to prevent, treat and identify changes in pressure ulcers for 1 of 2 sampled residents (#67) reviewed for pressure ulcers. Resident 67 acquired a pressure ulcer which became severely infected resulting in gas gangrene (a life threatening condition in which a bacterial infection produces toxins that release gas and cause tissue death) and required acute care intervention. Findings include: Resident 67 admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689May 25, 2021

  Based on interview and record review it was determined the facility failed to execute fall risk interventions for 1 of 3 residents (#5) reviewed for abuse. Resident 5 experienced a fall and sustained a right proximal humeral fracture (a break in the upper part of the bone in the arm) and experienced increased pain. Findings include: A public complaint was received on 4/30/21 indicating Resident 5 fell out of her/his bed onto the floor during the process of morning resident care. Resident 5 was transported to the emergency room . It was reported there was only one caregiver providing care. Resident 5 admitted to the facility in 2018 with diagnoses including stroke and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF809Feb 10, 2023

  Based on observation, interview and record review it was determined the facility failed to ensure the time between the start of the evening meal and the start of the breakfast meal did not exceed 14 hours without providing a substantial evening snack and snacks were suitable and available at non-traditional times for 1 of 1 facility, 1 of 3 facility snack refrigerators and 2 of 7 sampled residents (#s 29 and 35) reviewed for food and dining. This placed residents at risk for unmet nutritional needs and hunger. Findings include: 1. A review of the meal service times revealed dinner started at 4:30 PM and breakfast started at 7:30 AM, a span of 15 hours. […]

• No harm, potential for more than minimal, widespreadF812Feb 10, 2023

  Based on observation, interview and record review it was determined the facility failed to ensure standard food safety practices were followed for 1 of 1 kitchen and 2 of 2 unit refrigerators. This placed residents at risk for food borne illnesses. 1. On [DATE] the documented dinner time for residents began at 4:30 PM. On [DATE] at 3:05 PM the kitchen steam table was observed with cooked food on the steam table line including: whole black beans and a container of pureed green food. Three additional unidentified food containers sat in the steam table covered with foil. On [DATE] at 4:08 PM Staff 38 (Dietary Aide) stated he was the designated cook for dinner and started to prepare the puree foods around 12:30 PM and placed them on the steam table beginning at 1:00 PM. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2022

  Based on observation, interview and record review it was determined the facility failed to ensure the kitchen for 1 of 1 kitchen reviewed. This placed residents at risk for foodborne illness. Findings include: On 1/6/22 at 7:27 AM observations of the kitchen revealed the following: -Staff hand washing sink had rust around drain and hot and cold water nozzle. -Caulking on the back end of the staff hand washing sink had a build up of rust and the caulking was chipping on the back side of the sink. -Chipping paint on left side oven next to the cook stove. -Kitchen appliances including stove burners and deep fryer had dirt/grease build up. […]