Coos County Nursing Home

In the surveyor’s words

From the most serious findings on record at Coos County Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Feb 26, 2026

  Based on observation, interview and record review it was determine that the facility failed to implement the facility's infection control policies for 1 of 1 residents reviewed for transmission based precautions (Resident identifier is #1) and hand hygiene for 1 of 4 residents observed for medication administration (Resident identifier is #74). The facility failed to implement monitoring measures in the a water management plan that has the potential to effect a census of 74 residents. Findings include: Resident #1 Observation on 2/24/26 at approximately 10:47 a.m. revealed a contact precautions sign outside Resident #1's room. Further observation revealed Staff H (Housekeeping) exiting Resident #1's room wearing gloves and surgical mask and no gown. […]

• No harm, potential for more than minimal, isolatedF759Feb 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5 percent (%) for 3 of 29 medication administrations observed. (Resident identifier is #74).Findings include:Observation on 2/25/26 at approximately 9:10 a.m. of Staff A (Licensed Practical Nurse) revealed Staff A prepared the following 2 medications for Resident #74: Eliquis 2.5 milligrams (mg) tablet and Lantus Insulin 100unit/milliliters (ml) injector pen. […]

• No harm, potential for more than minimal, isolatedF604Dec 18, 2024

  Based on observation, record review, and interview, it was determined that the facility failed to keep residents free from physical restraints for 1 of 1 residents reviewed for physical restraints in a final sample of 18 residents (Resident identifier is #72). Findings include: Observation on 12/16/24 at approximately 12:00 p.m. revealed Resident #72 in the unit dining room, sitting in his/her broda chair with the back wheels locked, and his/her feet on the ground. Resident #72 was attempting to push back away from the table and attempted to tip table over. Interview on 12/16/24 at approximately 12:00 p.m. with Staff J (Licensed Nursing Assistant) confirmed the back wheels of Resident #72's broda chair were locked and the resident was unable to move the broda chair back. […]

• No harm, potential for more than minimal, isolatedF609Dec 18, 2024

  Based on interview and record review, it was determined that the staff failed to report an alleged violation of abuse immediately to the Administrator and the facility failed to report to the State Survey Agency (SSA) for 1 of 1 resident reviewed for abuse in a final sample of 18 residents (Resident identifier is #57). Findings include: Review on 12/16/24 of Resident #57's provider progress notes, written by Staff B (Advanced Practice Registered Nurse), revealed the following: 12/10/24, .Resident states [pronoun omitted] R [right] shoulder is in increased pain. [pronoun omitted] says one of the LNA's [Licensed Nursing Assistant] pulled [pronoun omitted] and [pronoun omitted] has [pronoun omitted] right shoulder and upper arm hurts now . Interview on 12/17/24 at approximately 2:15 p.m. […]

• No harm, potential for more than minimal, isolatedF644Dec 18, 2024

  Based on record review and interview, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorder and intellectual disability for a Level I Pre-Admission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed for PASARR in a final sample of 18 residents (Resident identifier is #1). Findings include: Review on 12/16/24 of Resident #1's most recent Level I PASARR screening completed on 7/23/13 for new admission, revealed no indication of mental illness or intellectual disability. Review on 12/16/24 of Resident #1's medical diagnosis list revealed a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 8/22/24 and Personal History of Traumatic Brain Injury (TBI) dated 8/3/17. […]