Inspection Reports for Avamere Rehabilitation of Coos Bay
2625 Koos Bay Blvd, OR, 97420
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20
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Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 40
Nov 18, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2021 to 2025 with detailed deficiency history and enforcement findings.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failure to follow physician orders, inadequate staffing, failure to provide timely care and notifications, medication errors, infection control issues, and failure to maintain a safe environment. Some deficiencies were corrected while others remained uncorrected at the time of inspections.
Complaint Details
Multiple inspections included complaint investigations related to abuse, neglect, medication errors, infection control, and staffing concerns.
Deficiencies (40)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0558 - Reasonable Accommodations Needs/Preferences: Failed to ensure call lights were within reach and incontinent supplies were sufficient. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify family of resident hospitalization. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain clean resident rooms and comfortable temperatures. |
| F0600 - Free from Abuse and Neglect: Verbal abuse by Staff 24 (RN) towards Resident 20. |
| F0602 - Free from Misappropriation/Exploitation: Misappropriation of resident funds by Staff 34 (CNA). |
| F0609 - Reporting of Alleged Violations: Failed to timely report bruising of Resident 41 to State agency. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to investigate injury of unknown origin for Resident 47. |
| F0627 - Inappropriate Discharge: Failed to confirm home health services after discharge for Resident 22. |
| F0628 - Discharge Process: Failed to notify Ombudsman of resident discharges. |
| F0637 - Comprehensive Assessment After Significant Change: Failed to complete significant change assessment for Resident 13. |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to develop care plans for Residents 34 and 35 for respiratory and hearing aids. |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans timely for Residents 19, 23, 24, and 41. |
| F0658 - Services Provided Meet Professional Standards: Failed to initiate CPR for Resident 1, an immediate jeopardy situation. |
| F0678 - Cardio-Pulmonary Resuscitation (CPR): Failed to perform CPR on Resident 1 found unresponsive. |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to provide ongoing activities for Resident 35. |
| F0684 - Quality of Care: Failed to follow physician orders and monitor bowel care and medications for multiple residents. |
| F0685 - Treatment/Devices to Maintain Hearing/Vision: Failed to ensure hearing aids were in place for Resident 35. |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to provide ROM services and equipment for Resident 4. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to assess falls and provide supervision for Residents 16, 22, 25, and 52. |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to provide timely incontinence care for Residents 6 and 15. |
| F0692 - Nutrition/Hydration Status Maintenance: Failed to provide nutritional services for Resident 35. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to maintain oxygen equipment and provide respiratory care for multiple residents. |
| F0697 - Pain Management: Failed to effectively manage pain for Resident 1. |
| F0698 - Dialysis: Failed to ensure dialysis services and documentation for Residents 13 and 16. |
| F0725 - Sufficient Nursing Staff: Failed to provide adequate nursing staff and respond timely to call lights. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to staff RN for 8 consecutive hours 7 days a week for multiple days. |
| F0732 - Posted Nurse Staffing Information: Failed to ensure accurate daily staff posting for 55 days. |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to maintain adequate medication supply for pain medications. |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to follow pharmacist recommendations timely for Resident 30. |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failed to monitor cholesterol medications for Residents 4 and 17. |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to monitor psychotropic medication for Resident 24. |
| F0760 - Residents are Free of Significant Med Errors: Medication errors with timing and administration for Residents 5 and 30. |
| F0761 - Label/Store Drugs and Biologicals: Failed to properly label and store medications; expired medications found. |
| F0788 - COVID-19 Vaccination of Facility Staff: Failed to accurately track COVID-19 vaccination status of Staff 37. |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to provide timely emergency dental services for Resident 9. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure sanitary food preparation and equipment sanitation. |
| F0840 - Use of Outside Resources: Failed to have dialysis agreement in place for Resident 45. |
| F0880 - Infection Prevention & Control: Failed to ensure clean smoking aprons and hygienic laundry processing. |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC NHSN. |
Report Facts
Total inspections: 10
Total deficiencies: 64
Licensing violations: 20
Abuse violations: 0
Notices: 0
Date range of inspections: From 2021-07-28 to 2025-11-18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 3 | RN | Named in failure to perform CPR finding for Resident 1 |
| Staff 4 | LPN | Named in failure to perform CPR finding for Resident 1 |
| Staff 24 | RN | Named in verbal abuse finding for Resident 20 |
| Staff 34 | CNA | Named in misappropriation of resident funds finding |
| Staff 2 | DNS (Director of Nursing Services) | Frequently named in findings and plans of correction |
| Staff 5 | RNCM (Resident Care Manager) | Named in misappropriation and other findings |
| Staff 37 | RN | Named in COVID-19 vaccination tracking deficiency |
| Staff 30 | RA (Restorative Aide) | Named in behavioral health and abuse related findings |
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