Avamere Rehabilitation Of Coos Bay

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0580 during a standard health inspection conducted on 2025-08-25.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to report a bruise of unknown origin for 1 of 3 sampled residents (#41) reviewed for abuse.

This placed residents at risk for abuse.

Findings include:Resident 41 admitted to the facility on [DATE] with diagnoses including heart failure and pain. A 6/14/25 physician order instructed staff to complete weekly skin checks on the resident's shower days and document on the Weekly Skin Audit. A 7/14/25 physician order instructed staff to administer apixaban 5 mg (anticoagulant) two times a day for blood clots. Resident 41's Annual MDS completed on 8/7/25 revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment.

The 8/15/25 Alert Note indicated the nurse was notified Resident 41 had a long, dark bruise on the underside of her/his right breast. Resident 41 was unable to explain how the bruising occurred and did not complain of pain. No documentation was found to indicate staff notified the State Agency.On 8/19/25 at 10:53 AM, Resident 41 was unable to recall if she/he had any bruises.On 8/20/25 at 4:04 PM, Staff 17 (LPN) confirmed on 8/14/25 he was notified Resident 41 had a large bruise on her/his right breast.

The resident did not recall how the bruise occurred.

Staff 17 noted the resident was on anticoagulant medication and bruised easily.

Staff 17 initiated a risk management report but did not report the incident to the State agency.On 8/21/25 at 4:42 PM, Staff 2 (DNS) was asked to provide copies of all internal and facility reported incidents (FRIs) that involved alleged abuse.

Staff 2 confirmed on 8/14/25 staff identified a bruise on Resident 41, the resident was unable to state how the bruise was acquired, and the incident was not reported to the State agency.

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of Coos Bay

2625 Koos Bay Blvd Coos Bay, OR 97420

SUMMARY STATEMENT OF DEFICIENCIES

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure therapy was ordered for a discharged resident for 1 of 2 sampled residents (#22) reviewed for discharge.

This placed residents at risk for lack of timely services after discharge.

Findings include: Resident 22 was admitted to the facility in 7/2022 with a diagnosis of a stroke. Resident 3's 7/31/25 Discharge Summary and Plan revealed she/he was discharged on 7/31/25 and a Home Health Agency referral was submitted.

The expected start of care was 8/4/25. On 8/18/25 at 4:56 PM Witness 4 (Complainant) stated Resident 22 just received orders for therapy on 8/18/25. On 8/20/25 at 2:46 PM Staff 12 (Social Services) stated Resident 22's discharge was resident driven.

The facility therapy department recommended two additional weeks of therapy, but Resident 22's family wanted her/him to discharge on [DATE].

Home Health physical therapy and occupational therapy orders were recommended but the orders were not signed before the resident was discharged because the physician was not in the facility. On 8/21/25 at 9:43 AM Witness 2 (Assisted Living Executive Director) stated Resident 22's home health services were delayed. On 8/21/25 at 4:52 PM Witness 3 (Home Health Manager) stated they did not receive therapy orders until Resident 22 went to her/his Primary Care Physician, and that physician's office sent the orders.

Witness 3 stated on 8/18/25 Resident 22 was accepted into home health therapy services.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of Coos Bay

2625 Koos Bay Blvd Coos Bay, OR 97420

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident 22's clinical record revealed the state long term care ombudsman (LTCO) was not notified of the resident's facility discharge.

The 7/2025 Ombudsman Notice of Residents Discharge form did not include Resident 22.

On [DATE] at 12:25 PM Staff 11 (Regional Director of Quality Assurance) verified there was no documentation the LTCO was notified of Resident 22's discharge.

• Resident 56 was admitted to the facility in 8/2023 with diagnoses including acute respiratory failure with

hypercapnia (excess carbon dioxide in the blood) and chronic systolic heart failure (long-term condition where the heart has difficulty pumping blood).

Progress Notes indicated Resident 56 was admitted to the hospital on [DATE].

A review of Ombudsman Notice of Residents Discharge forms for 6/2025 and 7/2025 did not include Resident 56's name.

On [DATE] at 10:47 AM, Staff 12 (Social Services) stated she sent a monthly fax to the Long-Term Care Ombudsman's (LTCO) office listing all resident discharges. No additional information was provided.

On [DATE] at 11:25 AM, an attempt to contact the LTCO office was not successful.

On [DATE] at 11:49 AM, Staff 2 (DNS) stated the LTCO office would be expected to be notified monthly if a resident went to the hospital and returned. If a resident died, the LTCO office would be expected to be notified as soon as the facility became aware of the death.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avamere Rehabilitation of Coos Bay

2625 Koos Bay Blvd Coos Bay, OR 97420

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-08-25.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0684 during a complaint investigation conducted on 2025-08-25.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-25.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-08-25.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-25.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0725 during a standard health inspection conducted on 2025-08-25.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-08-25.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-08-25.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-25.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0791 during a standard health inspection conducted on 2025-08-25.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide or obtain dental services for each resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-25.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.

Federal health inspectors cited AVAMERE REHABILITATION OF COOS BAY in COOS BAY, OR for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-25.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 17 deficiencies cited during this inspection of AVAMERE REHABILITATION OF COOS BAY.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-11.