Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coos County Nursing Home during CMS and state inspections, most recent first.
Infection control practices were not followed for a resident on contact precautions and during an insulin medication pass. Staff entered the resident’s room without the required PPE, failed to remove gloves appropriately, and an LPN did not perform hand hygiene after removing gloves before preparing another resident’s medications. The facility also did not follow its Legionella water management monitoring requirements, including boiler temperature tracking, resident room temperature checks, and documentation of flushing for empty rooms.
Medication administration errors exceeded the allowed rate when an LPN failed to perform the required safety test on an insulin pen before injection and initially omitted two scheduled morning meds for a resident. The resident questioned the missing meds, and the LPN then retrieved and administered the omitted Vitamin B12 and metoprolol. The observed errors resulted in a 10.34% error rate.
A facility failed to keep a resident free from physical restraints, as the resident was observed in a Broda chair with locked wheels, restricting movement. Staff confirmed the wheels were locked to keep the resident at the dining table, but no physician orders or care plans authorized this restraint. The facility's policy requires alternatives to be tried first and a physician's order for restraints, which was not followed.
The staff failed to report an alleged abuse incident immediately to the Administrator and the State Survey Agency. A resident reported increased pain in their right shoulder after an LNA allegedly pulled them. Staff B, an APRN, documented the complaint but did not report it to the administrator. The facility's policy requires immediate reporting of such incidents to the NHA and DON, which was not followed.
A facility failed to refer a resident with newly diagnosed PTSD and a history of TBI for a Level I PASARR screening. The resident exhibited aggression and confusion, and although interventions were in place, there was no process for a new PASARR referral. The Social Services Director confirmed the absence of such a process.
A facility failed to follow physician orders for a resident with pressure ulcers. An LPN was observed changing a dressing on the resident's coccyx and found an additional dressing on the left gluteal fold without a physician's order. The LPN was unaware of any such order, and a review confirmed its absence. The Assistant DON/Wound Nurse stated that dressings should not be applied without a physician's order.
A resident developed a pressure ulcer on the left heel due to the facility's failure to provide timely treatment and update the care plan. Initially identified as a bruise, the condition progressed to a blister before treatment orders were issued. Interventions to offload pressure were delayed, as confirmed by the ADON and DON.
A resident with obstructive sleep apnea did not receive proper CPAP care due to a torn mask, which staff were aware of but did not report to the provider. The issue persisted for at least a week, with multiple documented instances of the CPAP being non-functional.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care documentation. One resident's transfer method was not updated in their profile, while another resident's death was not properly documented. These discrepancies were confirmed by staff and violated the facility's policies.
Infection Control and Water Management Failures
Penalty
Summary
The facility failed to implement its infection control policies for transmission-based precautions for one resident on contact precautions. A contact precautions sign was posted outside the resident’s room, but a housekeeping staff member exited the room wearing gloves and a surgical mask and did not remove the gloves when leaving. On another observation, an LNA entered the resident’s room wearing a surgical mask and adjusted the resident’s privacy curtain without gloves or a gown. The Infection Preventionist confirmed the resident was on contact precautions and stated staff were expected to don gloves, gown, and surgical mask before entering the room regardless of the intervention being performed. The facility’s Contact Precautions policy and posted CDC signage both directed staff to wear PPE before room entry and remove gloves before room exit. The facility also failed to follow hand hygiene expectations during medication administration for one resident. During a medication pass, an LPN applied gloves, administered insulin to the resident, removed the gloves, and then went to the medication cart and began preparing another resident’s medications without performing hand hygiene. The LPN confirmed the observation, and the Infection Preventionist stated the expectation was for staff to perform hand hygiene after gloves are removed. The facility’s Handwashing/Hand Hygiene policy stated that alcohol-based hand rub may be used after removing gloves and that glove use does not replace handwashing or hygiene. In addition, the facility’s Legionella Water Management monitoring was not being carried out as written: boiler water temperatures did not meet the 140-degree F expectation on multiple days in January and February, weekly resident room temperatures were being taken in dining rooms instead of resident rooms, there was no evidence of flushing for empty rooms, and resident room temperatures had not been checked since 2/28/25.
Medication Administration Error Rate Exceeded
Penalty
Summary
Medication administration errors exceeded the required threshold when 3 of 29 observed administrations were in error, resulting in a 10.34% error rate. During observation of Staff A, an LPN, preparing medications for Resident #74, Staff A prepared Eliquis 2.5 mg and Lantus Insulin 100 unit/ml injector pen, but set the insulin pen dial to 14 without first performing the required safety test on the pen. Review of Resident #74’s MAR showed that two additional morning medications, Vitamin B12 500 mcg and Metoprolol Succinate ER 50 mg, were scheduled but not initially prepared. When the LPN administered the Lantus, the resident asked where the other medications were, and Staff A then returned to the medication cart, poured the missed medications, and administered them. Staff A confirmed the findings during interview. Manufacturer instructions for the Lantus pen required a safety test before each injection, and the facility’s medication administration policy stated medications are to be administered as prescribed in accordance with manufacturer specifications and that orders are to be reviewed and confirmed prior to administration.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed during a survey. On two separate occasions, the resident was found in the dining room sitting in a Broda chair with the back wheels locked, preventing movement. The resident attempted to push back from the table and tip it over, indicating a restriction of movement. Staff confirmed that the wheels were locked to keep the resident at the table during meals. A review of the resident's records showed no physician orders, assessments, or care plans authorizing the use of restraints. The facility's policy on physical restraints, dated 2006, states that restraints should only be used after alternatives have been tried unsuccessfully and require a physician's order with an associated diagnosis. The policy also specifies that restraints should not be used for staff convenience or to limit resident mobility, which was not adhered to in this case.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The staff at the facility failed to report an alleged violation of abuse immediately to the Administrator and did not report the incident to the State Survey Agency (SSA) for a resident reviewed for abuse. The deficiency was identified through an interview and record review. The resident reported increased pain in their right shoulder, stating that a Licensed Nursing Assistant (LNA) had pulled them, resulting in pain in the right shoulder and upper arm. Staff B, an Advanced Practice Registered Nurse, documented the resident's complaint in the provider progress notes but did not report the allegation to the administrator. The facility's policy requires immediate notification of the Nursing Home Administrator (NHA) and Director of Nursing (DON) or their designees of all incidents of mistreatment, abuse, neglect, and misappropriation of resident property. The policy also mandates that observation or suspicion of alleged resident abuse, neglect, or misappropriation of resident property must be reported and investigated immediately.
Failure to Refer Resident for PASARR Screening
Penalty
Summary
The facility failed to refer a resident with newly identified mental health conditions for a Level I Pre-Admission Screening and Resident Review (PASARR). The resident, who was initially admitted without indications of mental illness or intellectual disability, was later diagnosed with Post Traumatic Stress Disorder (PTSD) and had a history of Traumatic Brain Injury (TBI). Despite these diagnoses, the facility did not initiate a new PASARR screening, which is required when a resident develops a serious mental disorder or intellectual disability. The deficiency was identified during a review of the resident's medical records and an interview with the Social Services Director. The resident exhibited behaviors such as aggression and confusion, which were documented in mental health provider notes and the Minimum Data Set (MDS) assessment. The care plan included interventions for PTSD and TBI, but there was no process in place for referring the resident for a new PASARR screening. The Social Services Director confirmed the lack of a referral process for newly identified mental or intellectual disabilities.
Failure to Follow Physician Orders for Dressing Application
Penalty
Summary
The facility failed to follow physician orders for a resident with pressure ulcers. During an observation, a Licensed Practical Nurse (LPN) was seen changing a dressing on the resident's coccyx and discovered an additional dressing on the resident's left gluteal fold, which was dated the previous day. The LPN was unaware of any physician orders for this additional dressing. A review of the resident's Treatment Administration Record (TAR) and physician's orders confirmed that there was no order for the dressing applied to the left gluteal fold. An interview with the Assistant Director of Nurses/Wound Nurse revealed that a dressing should not be applied without a physician's order.
Failure to Prevent and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer on a resident's left heel, which was initially identified as a bruise on November 8th. Despite the bruise being noted during a weekly skin check, no treatment orders were issued until November 10th, when the bruise had progressed to a blister. The resident was described as very lethargic and had been in bed for an extended period, which may have contributed to the development of the blister. The blister was noted to be draining serous fluid, and a medical doctor was notified, resulting in a new order for treatment. The resident's care plan was not updated with new interventions until November 21st, despite the blister being identified on November 10th. The interventions included keeping the heels elevated and using a Multiboot to offload pressure from the heel. However, these interventions were not initiated until November 20th, 12 days after the initial identification of the bruise. Interviews with the Assistant Director of Nursing/Wound Nurse and the Director of Nursing confirmed the delay in treatment orders and care plan updates, indicating a lapse in timely and appropriate care for the resident's pressure ulcer prevention and management.
Failure to Provide Proper CPAP Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with an order for a CPAP machine. The resident, who has obstructive sleep apnea, reported that they had been unable to use their CPAP at night due to the mask not sealing properly. This issue had persisted for at least a week, and staff were aware of the problem. A review of the resident's medical record showed multiple entries indicating that the CPAP mask was torn or the machine was broken on several occasions. Despite these documented issues, no one had notified the provider about the CPAP not being used as ordered, as confirmed by a registered nurse during an interview.
Inaccurate Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care documentation. For one resident, it was discovered through interviews and record reviews that the resident had been using a hoyer lift for transfers for several weeks. However, the Resident Profile in the resident's closet still indicated the use of a mechanical stand lift with two-person assistance. This discrepancy was confirmed by the Director of Rehabilitation and the Director of Nursing, who acknowledged that the Resident Profiles are part of the medical record and should be updated with any changes in care needs. The facility administrator also expressed the expectation that Resident Profiles be updated promptly. In another case, the facility failed to document the pronouncement of death for a resident. The progress notes for the resident included an entry indicating that the resident was not breathing and that a registered nurse was notified to pronounce death. However, there was no documentation in the progress notes regarding the actual pronouncement of death. This omission was confirmed by the Director of Nursing, and a review of the facility's policy on the death of a resident highlighted the requirement for licensed nurses to document the time of death and the pronouncement by a physician or registered nurse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Berlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Vincent Rehabilitation & Nursing Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Country Village Center, Genesis Healthcare | 19.8 mi | ★★★★★ | 8 | 0 |
| Morrison Nursing Home | 22.7 mi | ★★★★★ | 7 | 0 |
| Merriman House | 28.8 mi | — | 0 | 0 |
| Rumford Community Home | 30.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Coos County Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.