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Avamere Rehabilitation of Coos Bay

2625 Koos Bay Blvd, Coos Bay, OR 97420 · Coos County · (541) 267-2161

92 certified beds, about 55 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1994

Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 385239 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on August 25, 2025, inspectors cited 17 health deficiencies (the Oregon average is 9.2, the national average 9.2).

Of 45 health citations since March 2023, 3 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).

CMS lists 1 fine totaling $15,593 in the last three years; the largest was $15,593, and the latest is dated November 22, 2023.

Nurses and nurse aides worked 4.59 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.58 of those hours.

34.2% of nursing staff left within the year CMS measured (Oregon average 47.4%).

CMS links it to Avamere, an affiliated group of 27 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 45 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
32D
8E
2F
Potential for minimal harm
0A
0B
0C
August 25, 2025Standard inspection, Complaint inspection · 17 citations
  1. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to have an on-hand supply of emergency hypoglycemic medication and administer anti-seizure medications according to provider orders for 2 of 13 residents (#s 5, and 30) reviewed for insulin and medication errors. This placed residents at risk for serious adverse health outcomes and death.
  2. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 15 sampled residents (#s 3, 5, 21, and 59) reviewed for medications, insulin, medication administration, and tube feedings. This placed residents at risk for adverse medication effects.
  3. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 5 of 10 sampled residents (#s 1, 7, 24, 52, and 61) reviewed for staffing. This placed residents at risk for unmet needs.
  4. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident medications were not expired for 1 of 1 medication storage room, 1 of 2 medication carts, and 1 of 1 treatment carts reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications.
  5. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation and interview it was determined the facility failed to ensure an ice machine drain had an airgap to prevent back flow for 1 of 1 kitchen. This placed residents at risk for foodborne illness.
  6. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident had correct sized incontinence products for 1 of 3 sampled residents (#3) reviewed for environment. This placed residents at risk for skin breakdown.
  7. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's family of a hospitalization for 1 of 2 sampled residents (#3) reviewed for hospitalization. This placed residents at risk for lack of family involvement.
  8. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased 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.
  9. D
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    F627 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased 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.
  10. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the state Long Term Care Ombudsman's office was notified of facility discharges for 3 of 4 sampled residents (#s 3, 22, and 56) reviewed for discharges and hospitalization. This placed residents at risk for lack of advocacy.
  11. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observations, interview, and record review it was determined the facility failed to ensure the resident's care plan was comprehensive for 1 of 3 sampled residents (#41) reviewed for abuse. This placed residents at risk for increased complications related to anticoagulant medication use.
  12. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 9 sampled residents (#52) reviewed for staffing. This placed residents at risk for accidents.
  13. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received timely incontinence care for 2 of 10 residents (#6 and 15) reviewed for staffing. This placed residents at increased risk for skin breakdown and loss of dignity.
  14. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide respiratory care and services for 1 of 1 sampled resident (#6) reviewed for medications and respiratory services. This placed residents at risk for unmet respiratory needs.
  15. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's pain medication was available for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for uncontrolled pain.
  16. D
    Provide or obtain dental services for each resident.
    F791 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's denture was replaced timely for 1 of 1 sampled resident (#3) reviewed for dental. This placed residents at risk for weight loss.
  17. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 11, 2025
    Inspectors wroteBased on observation and interview it was determined the facility failed to provide clean and sanitary smoking equipment for 1 of 4 sampled residents (#21) reviewed for smoking. This placed residents at risk for respiratory issues and cross-contamination.
May 3, 2024Standard inspection, Complaint inspection · 13 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to handle and prepare food in a sanitary manner for 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for food borne illness.
  2. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for contaminated laundry.
  3. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals, and failed to ensure proper storage temperatures were logged and maintained for 2 of 2 treatment carts and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and adverse medication side effects.
  4. D
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident rooms were cleaned for 1 of 3 sampled residents (#9) reviewed for environment. This placed residents at risk for lack of a homelike environment.
  5. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to protect residents' right to be free from verbal abuse from Staff 24 (RN) for 1 of 1 sampled resident (#20) reviewed for abuse. This placed residents at risk for abuse.
  6. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from misappropriation by Staff 34 (CNA) for 1 of 1 sampled resident (#302) reviewed for misappropriation of personal funds. This placed residents at risk for financial abuse.
  7. D
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents with contractures received ROM services and equipment to prevent further decrease in ROM and skin breakdown for 1 of 1 sampled resident (#4) reviewed for mobility. This placed residents at risk worsening contractures.
  8. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to assess falls and provide treatment to prevent falls for 1 of 1 sampled resident (#25) reviewed for accidents. This placed residents at risk for falls and injuries.
  9. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed ensure oxygen was administered as ordered and maintain oxygen concentrators for 2 of 3 sampled residents (#s 36 and 251) reviewed for oxygen therapy. This placed residents at risk for increased risk for respiratory failure.
  10. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to follow pharmacist recommendations in a timely manner for 1 of 5 sampled residents (#30) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration.
  11. D
    Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
    F840 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to have a dialysis agreement in place for 1 of 1 sampled resident (#45) reviewed for dialysis. This placed residents at risk for not receiving dialysis services.
  12. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to accurately document medication administration for 1 of 4 sampled residents (#33) reviewed for physician orders. This placed residents at risk for inaccurate medical records.
  13. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were offered a pneumonia vaccine for 1 of 5 sampled residents (#30) reviewed for immunizations. This placed residents at risk for infections.
November 22, 2023Complaint inspection · 2 citations
  1. J
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Staff 3 (RN) and Staff 4 (LPN) adhered to professional standards of practice related to the provision of CPR (cardiopulmonary resuscitation) on a resident found with no heartbeat and not breathing for 1 of 1 sampled resident (#1) reviewed for Death/CPR. This failure, determined to be an immediate jeopardy situation, resulted from the failure to initiate CPR for the resident according to physician's orders. This failure prevented the possible resuscitation and continued life of Resident 1.
  2. J
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    F678 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review it was determined the facility failed to perform CPR (Cardiopulmonary Resuscitation) on a resident found with no heartbeat and not breathing for 1 of 1 sampled residents (#1) reviewed for Death/CPR. This failure, determined to be an immediate jeopardy situation, resulted from the facility failing to initiate CPR for Resident 1 according to physician's orders. This failure prevented the possible resuscitation and continued life of Resident 1. Without immediate action to correct the failure the 19 other full code residents at the facility were at risk for not being resuscitated.
March 10, 2023Standard inspection · 13 citations
  1. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure comfortable temperatures were maintained in all areas of the facility for 1 of 1 facility. This placed residents at risk for an uncomfortable environment.
  2. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview and record review it as determined the facility failed to follow physician orders and ensure bowel care interventions were followed for 3 of 5 sampled residents (#s 6, 16 and 24) reviewed for medications. This placed residents at risk for unmet needs and bowel complications.
  3. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation and interview it was determined the facility failed to ensure equipment was properly sanitized for 1 of 1 kitchen reviewed. This placed resident at risk for food borne illnesses. During random observations on 3/6/23 and 3/10/23 in the common dining room, plastic pitchers were observed in use by CNAs who assisted residents by pouring their beverages of choice during meal service. On 3/6/23 from 10:15 AM to 11:30 AM the three compartment sink was observed not in use. On 3/9/23 at 10:30 AM Staff 23 (Dietary Aide) stated the three compartment sink was only used when the dishwasher was not working. Staff 23 was observed to touch a plastic pitcher held in an unused three compartment sanitation sink and stated the plastic pitchers could not be placed in the dish machine because the dish washer damaged the pitchers. [...]
  4. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure call lights were within reach for 2 of 2 sampled residents (#s 19 and 30) reviewed for call lights. This placed residents at risk for unmet needs.
  5. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to investigate an injury of unknown origin for 1 of 2 sampled residents (#47) reviewed for abuse. This placed residents at risk for abuse.
  6. D
    Assess the resident when there is a significant change in condition
    F637 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess and complete a significant change assessment for 1 of 1 sampled resident (#13) reviewed for dialysis. This placed residents at risk for unmet needs.
  7. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to revise care plans and conduct quarterly care planning conferences for 3 of 5 sampled residents (#s 19, 23 and 24) reviewed for ADLs, constipation and care planning. This placed residents at risk for unmet needs.
  8. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dialysis services were provided to 1 of 1 sampled resident (#16) reviewed for dialysis. This placed residents at risk for lack of dialysis services.
  9. D
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to reassess, implement and revise behavioral healthcare needs for 1 of 1 sampled resident (#12) reviewed for mood/behavior health. This placed residents at risk for unmet psychosocial wellbeing.
  10. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to monitor psychotropic medication for 1 of 5 sampled residents (#24) reviewed for medications. This place residents at risk for unnecessary medications.
  11. D
    Provide or obtain dental services for each resident.
    F791 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to promptly provide emergency dental services and interventions to meet residents' needs for 1 of 2 sampled residents (#9) reviewed for dental. This placed residents at risk for unmet dental needs.
  12. D
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure meals were provided to meet the needs of residents for 3 of 4 sampled residents (#s 13, 20 and 22) reviewed for food and kitchen. This place residents at risk for lack of adequate nutrition and allergic reactions.
  13. D
    Ensure staff are vaccinated for COVID-19
    F888 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to accurately track and document the COVID-19 status of 1 of 8 sampled facility staff (#37) reviewed for vaccinations. This placed residents at risk for infection.

Fire safety inspections

26 fire safety citations on file: 4 on May 3, 2024, 1 on March 10, 2023, 21 on January 27, 2022.

Every fire safety citation26 citations
  1. F
    Conduct testing and exercise requirements.
    E 39 · May 3, 2024 · Corrected (the home has a date of correction)
  2. F
    Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
    K 342 · May 3, 2024 · Corrected (the home has a date of correction)
  3. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · May 3, 2024 · Corrected (the home has a date of correction)
  4. D
    Meet other general requirements.
    K 932 · May 3, 2024 · Corrected (the home has a date of correction)
  5. E
    Have properly installed hallway dispensers for alcohol-based hand rub.
    K 325 · March 10, 2023 · Corrected (the home has a date of correction)
  6. F
    Establish an Emergency Preparedness Program (EP).
    E 1 · January 27, 2022 · Corrected (the home has a date of correction)
  7. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · January 27, 2022 · Corrected (the home has a date of correction)
  8. F
    Develop Emergency Preparedness policies and procedures.
    E 13 · January 27, 2022 · Corrected (the home has a date of correction)
  9. F
    Establish policies and procedures for sheltering.
    E 22 · January 27, 2022 · Corrected (the home has a date of correction)
  10. F
    Create arrangements with other facilities to receive patients.
    E 25 · January 27, 2022 · Corrected (the home has a date of correction)
  11. F
    Develop a communication plan.
    E 29 · January 27, 2022 · Corrected (the home has a date of correction)
  12. F
    Establish emergency prep training and testing.
    E 36 · January 27, 2022 · Corrected (the home has a date of correction)
  13. F
    Establish staff and initial training requirements.
    E 37 · January 27, 2022 · Corrected (the home has a date of correction)
  14. F
    Conduct testing and exercise requirements.
    E 39 · January 27, 2022 · Corrected (the home has a date of correction)
  15. F
    Install noncombustible or limited-combustible interior walls.
    K 163 · January 27, 2022 · Corrected (the home has a date of correction)
  16. F
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · January 27, 2022 · Corrected (the home has a date of correction)
  17. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · January 27, 2022 · Corrected (the home has a date of correction)
  18. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · January 27, 2022 · Corrected (the home has a date of correction)
  19. E
    Include a process for Emergency Preparedness collaboration.
    E 9 · January 27, 2022 · Corrected (the home has a date of correction)
  20. D
    Establish roles under a Waiver declared by secretary.
    E 26 · January 27, 2022 · Corrected (the home has a date of correction)
  21. D
    Provide emergency officials' contact information.
    E 31 · January 27, 2022 · Corrected (the home has a date of correction)
  22. D
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · January 27, 2022 · Corrected (the home has a date of correction)
  23. D
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · January 27, 2022 · Corrected (the home has a date of correction)
  24. D
    Meet requirements for the installation and maintenance of electrical systems.
    K 911 · January 27, 2022 · Corrected (the home has a date of correction)
  25. D
    Ensure proper usage of power strips and extension cords.
    K 920 · January 27, 2022 · Corrected (the home has a date of correction)
  26. D
    Meet other general requirements.
    K 932 · January 27, 2022 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
November 22, 2023Fine $15,593

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeOregonUnited States
All nursing staff (RN, LPN and aides)4.595.033.86
Registered nurses0.580.720.69
All nursing staff on weekends4.024.513.42
Nurse aides3.17
Licensed practical nurses0.84
Nursing staff turnover (share who left in a year)34.2%47.4%45.8%
Registered nurse turnover60.0%51.6%42.9%
Administrators who left0

CMS expects 3.70 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.82 on weekdays and 4.02 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.42 in April to June 2025 to 4.59 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20264.590.584.824.02 1.5%0 of 9055
Oct to Dec 20254.600.364.844.01 0.6%0 of 9253
Jul to Sep 20254.540.524.833.82 2.5%1 of 9249
Apr to Jun 20254.420.604.693.74 1.4%0 of 9150
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Oregon, Jan to Mar 20264.910.645.124.406.2%0.4% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Oregon

JobMedianMiddle halfEmployed
Oregon, all employers
CNAs (nursing assistants)$23.96$22.83 to $28.4014,800
LPNs and LVNs$38.69$35.11 to $43.604,260
Registered nurses$62.02$51.55 to $64.6339,730
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeOregonUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
11.814.913.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.01.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
2.02.01.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
3.32.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.01.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
11.820.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
4.75.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
19.813.915.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
20.521.423.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
21.716.112.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.11.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.72.41.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Avamere Rehabilitation of Coos Bay's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (62.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

62.5% this home

Better than the national rate

US median of homes 51.5% · Oregon: 52 better, 3 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 160 eligible stays.

Potentially preventable readmissions

8.2% this home

No different from the national rate

US median of homes 10.7% · Oregon: 3 better, 0 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 164 eligible stays.

Infections that led to a hospital stay

6.9% this home

No different from the national rate

US median of homes 7.1% · Oregon: 0 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 96 eligible stays.

Self-care and mobility at discharge

46.7% this home

Median of homes: Oregon59.2% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 75 residents counted.

Falls with major injury

0.0% this home

Median of homes: Oregon0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 114 residents counted.

New or worsened pressure ulcers

3.7% this home

Median of homes: Oregon2.6% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 114 residents counted.

Medication list given at discharge

100.0% this home

Median of homes: Oregon98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 55 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: COOS BAY REHABILITATION, LLC. CMS links this home to Avamere, a group of 27 nursing homes averaging 3 stars overall.

NameRoleTypeShareSince
Ariso LLCDirect ownership interestOrganization01/06/2006
Ari Operations, LLCIndirect ownership interestOrganization01/06/2006
Avamere Group LLCIndirect ownership interestOrganization01/06/2006
Midcap Finco LLC5% or greater security interestOrganization01/22/2010
Adams, NancyManaging control - governing bodyIndividual06/01/2025
Cavallo, GlenManaging control - governing bodyIndividual06/01/2025
Feakin, CodyManaging control - governing bodyIndividual06/01/2025
Funderberg, MichelleManaging control - governing bodyIndividual06/01/2025
Hill, KevinManaging control - governing bodyIndividual06/01/2025
Hoskins, ToniaManaging control - governing bodyIndividual06/01/2025
Inskeep, ToddManaging control - governing bodyIndividual06/01/2025
Kofstad, MaryManaging control - governing bodyIndividual06/01/2025
Munro, JolynnManaging control - governing bodyIndividual06/01/2025
Okoli, IkeManaging control - governing bodyIndividual06/01/2025
Polson, JustinManaging control - governing bodyIndividual06/01/2025
Powelson, MicheleManaging control - governing bodyIndividual06/01/2025
Reid, MistyManaging control - governing bodyIndividual06/01/2025
Sanders, AmandaManaging control - governing bodyIndividual06/01/2025
Simpson, AndrewManaging control - governing bodyIndividual06/01/2025
Strunk, ColbyManaging control - governing bodyIndividual06/01/2025
Vanderzanden, CarrieManaging control - governing bodyIndividual06/01/2025
Avamere Health Services LLCOperational/managerial controlOrganization01/01/2005
Avamere Skilled Advisors LLCOperational/managerial controlOrganization01/01/2005
Aronson, JeffreyOperational/managerial controlIndividual08/12/2024
Carr, KirstenOperational/managerial controlIndividual04/01/2022
Dana, JenniferOperational/managerial controlIndividual05/01/2022
Feakin, CodyOperational/managerial controlIndividual07/15/2025
Henriquez, NelsonOperational/managerial controlIndividual01/01/2024
Hoskins, ToniaOperational/managerial controlIndividual07/19/2024
Kofstad, MaryOperational/managerial controlIndividual02/13/2024
Loewen, MichelleOperational/managerial controlIndividual10/09/2023
Munro, JolynnOperational/managerial controlIndividual09/01/2023
Polson, JustinOperational/managerial controlIndividual02/10/2025
Powelson, MicheleOperational/managerial controlIndividual03/25/2015
Presley, YolandaOperational/managerial controlIndividual01/06/2025
Reid, MistyOperational/managerial controlIndividual01/02/2025
Rolison, ShirleyOperational/managerial controlIndividual05/20/2018
Simpson, AndrewOperational/managerial controlIndividual06/01/2024
Avamere Health Services LLCAdp of the SNFOrganization07/07/2025
Avamere Skilled Advisors LLCAdp of the SNFOrganization07/13/2025
Karl Rickard Miller Jr Revocable TrustAdp of the SNFOrganization08/04/2025
Adams, NancyAdp of the SNFIndividual12/31/2024
Aronson, JeffreyAdp of the SNFIndividual07/07/2025
Carr, KirstenAdp of the SNFIndividual04/01/2022
Dana, JenniferAdp of the SNFIndividual05/01/2022
Feakin, CodyAdp of the SNFIndividual01/01/2025
Funderberg, MichelleAdp of the SNFIndividual12/31/2024
Henriquez, NelsonAdp of the SNFIndividual01/01/2024
Hill, KevinAdp of the SNFIndividual03/12/2022
Inskeep, ToddAdp of the SNFIndividual01/21/2022
Kofstad, MaryAdp of the SNFIndividual02/13/2024
Loewen, MichelleAdp of the SNFIndividual10/09/2023
Munro, JolynnAdp of the SNFIndividual09/01/2023
Polson, JustinAdp of the SNFIndividual02/10/2025
Powelson, MicheleAdp of the SNFIndividual03/25/2015
Presley, YolandaAdp of the SNFIndividual01/06/2025
Reid, MistyAdp of the SNFIndividual01/02/2025
Rolison, ShirleyAdp of the SNFIndividual05/20/2018
Simpson, AndrewAdp of the SNFIndividual06/01/2024
Strunk, ColbyAdp of the SNFIndividual09/06/2022
Vanderzanden, CarrieAdp of the SNFIndividual01/01/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 13 problems in this area, most recently on August 25, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on August 25, 2025: "Reasonably accommodate the needs and preferences of each resident."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on August 25, 2025: "Ensure that residents are free from significant medication errors."
  4. When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on August 25, 2025: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 4.02 hours per resident per day, below the Oregon average of 4.51.

Other nursing homes nearby

Oregon contacts for a concern about a nursing home

These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.

Common questions

What is Avamere Rehabilitation of Coos Bay's Medicare star rating?
CMS rates Avamere Rehabilitation of Coos Bay 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Avamere Rehabilitation of Coos Bay get at its last inspection?
17 health deficiencies at the standard inspection on August 25, 2025. The Oregon average is 9.2.
Has Avamere Rehabilitation of Coos Bay been fined?
Yes. CMS lists 1 fine totaling $15,593 in the last three years.
Does Avamere Rehabilitation of Coos Bay accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Avamere Rehabilitation of Coos Bay?
CMS lists 61 owners and managers, and links the home to Avamere. Legal business name: COOS BAY REHABILITATION, LLC.

Sources

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