Avamere Rehabilitation of Coos Bay

In the surveyor’s words

From the most serious findings on record at Avamere Rehabilitation of Coos Bay, in the surveyor’s own words.

• Immediate jeopardy, isolatedF658Nov 22, 2023

  Based 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. Findings include: [NAME] 851 045 0040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. […]

• Immediate jeopardy, isolatedF678Nov 22, 2023

  Based 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. […]

• Actual harm, isolatedF760Aug 25, 2025

  Based 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. Findings include: 1. Resident 5 admitted to the facility in 4/2025 with diagnoses including end stage kidney disease and Type I diabetes. The facility’s 2024 Standing Physician Orders for diabetic management instructed staff to inject 1 gram glucagon when diabetic residents became unresponsive, or capillary blood glucose (CBG) was below 70 mg/dL. […]

• Actual harm, isolatedF689Jul 28, 2021

  Based on interview and record review it was determined the facility failed to ensure staff followed the care plan and ensured a mechanical lift was in safe operating condition for 2 of 5 sampled residents (#s 16 and 22) reviewed for accidents. Resident 16 experienced a fall and sustained bilateral lower leg fractures. Findings include: 1. Resident 16 was admitted to the facility in 11/2020 with diagnoses including stroke, dementia and [CONDITION(S)]. A Significant Change MDS dated [DATE] indicated Resident 16 was rarely understood and had short-and-long term memory issues. […]

• Actual harm, isolatedF600May 12, 2021

  Based on interview and record review it was determined the facility failed to ensure residents were free from abuse and neglect for 3 of 5 sampled residents (#s 1, 2 and 3) reviewed for abuse and neglect. Due to the neglect of care related to incontinence Resident 2 developed moisture related skin breakdown and worsening of a Stage 3 (full thickness tissue loss without visible muscle, tendon or bone) pressure ulcer. Findings include: 1. Resident 2 was admitted to the facility in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 1/4/21 Admission MDS indicated Resident 2 was cognitively intact. Resident 2's CAA for Pressure Ulcers and Urinary Incontinence dated 1/4/21 included the following: - Resident 2 was always incontinent of bladder. […]