Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Coos Bay during CMS and state inspections, most recent first.
A resident with severe cognitive impairment due to Alzheimer’s disease was repeatedly found in unusual positions in bed, leading CNAs and an RN to approve and implement the use of rolled blankets placed along both sides of the resident and a sheet tucked at the foot of the bed to keep the resident centered. These blankets and the tucked sheet were arranged in a way that restricted the resident’s ability to move and exit the bed, and another CNA later observed the resident appearing concerned while confined by the wadded blankets and wrapped sheet. The facility’s investigation determined that this use of blankets limited the resident’s movement and significantly deviated from resident-rights standards and facility policy regarding physical restraints.
A resident with MS who required assistance with transfers, dressing, and bed mobility was found to have marijuana in the room, which the resident said a friend had brought and removed after staff intervention. The next day, after staff reported smelling marijuana and described the resident as yelling, cursing, and kicking furniture, the social services director, medical records director, and an LPN informed the resident that care would be discontinued and that the resident would be discharged home the same day for violating the facility’s no-marijuana policy. Multiple staff entered the room, the resident refused to leave and became more upset, and law enforcement was contacted, while a notice of involuntary transfer and a discharge summary citing non-compliance with policy were completed without arranging home health services. Staff interviews later gave conflicting accounts about whether the resident had actually smoked marijuana, and the resident reported feeling overwhelmed, attacked, and without alternatives, illustrating that the discharge process did not ensure a safe and orderly transition consistent with the resident’s needs.
Incomplete grievance resolution documentation was identified for multiple resident grievances. The facility’s grievance policy required prompt resolution efforts and detailed recordkeeping, but six grievance forms from several months had incomplete documentation showing the grievances were resolved. The Administrator stated the process involved a Concern and Comment card, investigation by Social Services, and final sign-off when resolution steps were complete, and she confirmed the documentation was incomplete.
Hand hygiene was not completed during meal service when a CNA delivered lunch trays, assisted a resident with food, touched the resident and her own face, hair, and clothing, then delivered another tray without sanitizing her hands. The CNA stated she was unsure when hand hygiene was required and acknowledged she did not sanitize between tray delivery and touching other surfaces; the DNS stated staff were expected to perform hand hygiene before and after resident contact and between tray handling.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits: Two residents received psychotropic meds, including amitriptyline, sertraline, and trazodone, without documentation that they were informed of the risks and benefits before administration. One resident with fibromyalgia was cognitively intact but could not recall medication details, and an LPN confirmed no evidence of informed discussion. Another resident with anxiety and diabetes had ongoing MAR-documented use of sertraline and trazodone, and the DNS confirmed no documentation of informed consent.
Failure to timely report an abuse allegation involving a resident whose genitals were photographed and shown to other CNAs on a personal cell phone. A CNA said she witnessed the incident and reported it to the Administrator, but the allegation was not reported to the State Agency within the required timeframe; the DON and Administrator were initially unaware, and the Staffing Coordinator later confirmed she knew about the allegation but did not verify that it was reported.
Failure to provide written notice of hospital transfer for two residents. One resident with bipolar disorder and DM was sent out for confusion and unrelieved pain, and another resident with PNA had a change in condition and was sent to the hospital, but the record showed no written Notice of Transfer for either resident.
Failure to provide restorative therapy for a resident with a right leg fracture and sepsis. The resident said restorative services were supposed to continue after skilled therapy ended, but staff had not walked with the resident or done exercises for several weeks. CNAs gave conflicting statements about whether restorative aides existed and who completed the restorative program, and the DNS stated CNAs were expected to read and follow the care plan for restorative services.
Failure to follow physician orders for two residents. One resident with chronic PE and DM missed scheduled Eliquis doses, with MAR entries showing doses not given and staff unable to confirm the med was checked or reported appropriately even though Eliquis was available in the Omnicell. Another resident with a right shin wound had ordered dressing changes every 3 days, but the dressing remained dated 12/8 despite later MAR documentation of wound care, and LPNs could not confirm the ordered care was completed.
A resident with fibromyalgia had no documented urinary symptoms, yet a UA was collected without a physician order and later showed positive findings. An antibiotic was then ordered for UTI without evidence of a culture and sensitivity, and the Medical Director and DNS both confirmed the record lacked urinary complaints and an order for the UA.
A resident receiving thyroid replacement medication had an ordered TSH lab that was not drawn, even though the TAR showed the lab draw task was completed along with other ordered labs. The record contained results for the lipid panel and magnesium, but no TSH result, and an LPN confirmed the TSH should have been drawn with the other tests.
The facility failed to prevent accidents and update care plans for three residents, leading to falls and injuries. A resident with paralysis fell from a mechanical lift due to improper use by CNAs, while another with Parkinson's disease experienced multiple falls due to inadequate supervision and incomplete care plan updates. A third resident with a history of falls also had care plan deficiencies, contributing to repeated falls.
The facility failed to provide adequate pain management for two residents, resulting in unresolved severe pain. One resident with a pressure ulcer did not receive prescribed oxycodone for five days due to medication ordering issues, while another post-surgery resident was not given pain medication on admission despite authorization to use emergency supply, leading to an ER visit. Documentation was also lacking.
The facility did not ensure staffing information was posted in an accessible location and failed to provide accurate and complete data for several days. The Direct Care Staff Daily Report was placed above eye level behind the nurse's station, making it difficult to access. Additionally, the report was incomplete or missing data on multiple occasions, as acknowledged by the Staffing Coordinator.
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions for two residents with wounds, risking cross-contamination. A resident with rib fractures was not listed for EBP despite having a wound, and a physical therapist did not follow droplet precautions for another resident with a leg fracture, as they were not informed of the requirements.
The facility did not ensure CNAs received the required 12 hours of annual in-service training, as shown by records for five staff members. One CNA had no documented training, while others had less than the required hours. The DNS confirmed the deficiency, despite competency evaluations and training being conducted.
A facility failed to include a resident's guardian in care planning, as the guardian was not invited to care conferences since October 2023. The resident, diagnosed with autism, had a guardian who confirmed not being involved in care planning for a significant period. Despite staff efforts, no documentation was found to show the guardian's participation in care conferences.
The facility failed to document and follow up on advance directives for three residents, including one with rib fractures and another with diabetes and left-sided weakness. Despite care plans indicating the presence of advance directives, the clinical records lacked copies, and there was no documentation of offering or refusing directives. The Social Services Director acknowledged these deficiencies.
A resident with dementia was hospitalized following a change in condition, but the facility failed to notify the resident's representative, despite them being the first emergency contact. This deficiency was confirmed through interviews and a lack of documentation from the LPN responsible.
A facility failed to notify a resident's responsible party about a change in Medicare coverage. The resident, with moderate cognitive impairment, signed a Notice of Medicare Non-Coverage (NOMNC) form without the responsible party being informed. Staff interviews revealed a lapse in protocol, as the responsible party was not contacted or present during the signing, despite being known to the facility.
The facility failed to provide a safe and homelike environment for two residents due to uneven floors, causing furniture to roll and creating a risk of imbalance. One resident, with vertigo and unsteadiness, reported their room sloped visibly, while another resident required blocks under their bed to level it. Staff confirmed the issue, noting the building's U shape, and planned to move affected residents.
A resident with moderate cognitive impairment was involved in an incident with an agency LPN, who reportedly reacted aggressively after the resident pushed a bedside table into him. The LPN allegedly grabbed the resident's bed covers and pushed down on the resident's chest. Despite reports from witnesses and the resident's family, the facility did not investigate the incident, and documentation was missing.
A resident with moderate cognitive impairment was involved in an alleged abuse incident with an agency LPN, who reportedly had a physical altercation with the resident. Despite the incident being reported to the family, the facility failed to report it to the State Survey Agency, as required. Interviews confirmed the incident, and the facility's administration acknowledged the expectation to report such allegations.
A resident with cognitive impairment was allegedly abused by an agency LPN, who reportedly pushed down on the resident's chest after a confrontation. Despite the resident's fear and family notification, the facility failed to document an investigation into the incident, as confirmed by staff interviews.
The facility failed to update care plans for three residents, leading to unmet care needs. A resident with a shin wound had no care plan revision to address it. Another resident with a hand contracture required assistance with a soft hand roll, which was not included in the care plan. A third resident with a left ankle wound had no goals or interventions in their care plan. Staff acknowledged these oversights.
A resident with cognitive impairment and a stroke diagnosis was observed with long facial hair, despite preferring to be clean-shaven. The resident required assistance for ADLs, and a CNA acknowledged the resident had not been shaved for several days, contrary to the facility's routine of shaving on shower days.
The facility failed to provide care for a non-pressure skin injury and did not prepare a resident for a medical procedure. A resident with heart disease had a shin wound that was not assessed or treated properly, and the care plan was not updated. Another resident, admitted with a stroke, was not prepped for a sigmoidoscopy, leading to a delay in diagnosis. The lack of preparation was acknowledged by the DNS.
A resident with Parkinson's disease had contractures in their hands, but the facility failed to provide a treatment plan. The resident was able to communicate needs, and a family member was unaware of any ROM exercises being provided. The DNS confirmed the lack of a treatment plan.
A resident with an indwelling catheter experienced prolonged pain due to inadequate catheter care and documentation. Despite a care plan requiring regular catheter care and monitoring, staff failed to document urine output and address the resident's complaints of bladder pain. The issue was resolved only after a catheter change during the night shift, highlighting deficiencies in the facility's catheter care protocol.
A resident with Parkinson's disease and mental health disorders, who was at nutritional risk, did not receive scheduled snacks as per their care plan. The facility failed to document the provision of snacks, and the task was not correctly entered into the system, leading to a lack of adherence to the resident's nutritional care plan.
A facility failed to provide non-pharmacological interventions before administering medications and did not document a rationale for not reducing a resident's venlafaxine dose. The resident, diagnosed with dementia, was on multiple antidepressants, and a pharmacy consultation recommended tapering citalopram and reducing venlafaxine, but the latter was declined without rationale. Additionally, Ativan PRN was administered for anxiety without documented behaviors or non-pharmacological interventions.
The facility failed to obtain a blood sample for a resident with a stroke diagnosis, as instructed in the July 2024 TAR. Despite a request for the laboratory results, no additional information was provided, placing residents at risk for delayed treatment.
A resident with missing and decaying teeth was not offered a dental appointment, despite being cognitively intact and reporting cavities. The facility's staff failed to follow up on identified dental concerns, leading to a deficiency in care.
A resident with a UTI was inappropriately administered Cephalexin without confirming its effectiveness, leading to unnecessary antibiotic use. Despite urine culture results showing resistance to Cephalexin, it was not discontinued when Meropenem was started, resulting in both antibiotics being administered simultaneously. The DNS acknowledged the error.
Improper Use of Rolled Blankets as Physical Restraints in Bed
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident free from physical restraints when blankets were used in a manner that restricted movement. The resident, admitted with Alzheimer’s disease and documented on an admission MDS as severely impaired, rarely making decisions, and having disorganized thinking and altered level of consciousness, was found in bed with blankets tucked in on both sides of the body. A facility investigation dated 12/8/25 documented that the rolled blankets limited the resident’s movement and that staff had significantly deviated from resident-rights standards and facility policy. Written staff statements indicated that the resident had been repeatedly found in unusual or “weird” positions in bed, including lying sideways and in a praying position, prompting staff to attempt to keep the resident in the center of the bed. According to staff statements, two CNAs (Staff 3 and Staff 4) reported finding the resident in awkward positions on multiple occasions and decided to fold and roll blankets, placing them on both sides of the resident to keep the resident in what they believed was a safe position. Staff 4 documented that during rounds she saw the resident lying sideways and, after Staff 3 asked about using pillows, an RN (Staff 11) stated it was acceptable; when no pillows were available, blankets were rolled and placed under the resident on each side, with a sheet tucked in at the foot of the bed. Staff 11 reported the resident was hard of hearing and very wiggly and had been found with the head on one side of the bed and feet off the other side, though not on the floor, and that blankets were tucked under the mattress at the foot of the bed. Another CNA (Staff 5) later observed the resident grasp her arm with a concerned expression and noted blankets wadded on both sides and a sheet wrapped over and tucked under the blankets in a way that restricted movement. The DNS (Staff 2) confirmed that Staff 3 and Staff 4 should not have placed blankets in a way that restricted the resident’s movement.
Failure to Ensure Safe and Orderly Discharge After Marijuana Policy Violation
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe and orderly discharge for a cognitively intact resident with multiple sclerosis who required assistance with stand-pivot transfers, dressing, and bed mobility. The resident was admitted with MS and later found to have marijuana in the room, which the resident stated had been brought in by a friend. An assistant DNS documented that the marijuana was removed by the friend after the resident was educated on medication side effects. The next day, psychosocial notes indicated that the social services director and the medical records director informed the resident that care could no longer be continued and that the resident would be discharged home that same day for using marijuana in violation of facility policy, after staff reported smelling marijuana in the room. During this interaction, the resident became upset, yelled, and kicked a table, and additional staff, including an LPN unit care coordinator and other LPNs, entered the room. The LPN unit care coordinator told the resident the facility was federally funded, could no longer keep the resident, and that smoking combined with aggressive behavior meant the resident was not in the right facility. The resident yelled, cursed, and refused to leave while staff attempted to discuss discharge options and safe discharge education. A care management note documented that the resident had smoked marijuana in the facility, was yelling, berating staff, throwing items, and kicking the bedside table, and that discharge was deemed warranted with physician orders obtained. A Notice of Involuntary Transfer was issued the same day, citing that the resident’s behaviors created a serious and immediate threat, and the discharge summary listed the reason for discharge as non-compliance with facility policy, with discharge to home or community and no home health services indicated. Subsequent interviews revealed conflicting staff accounts regarding whether the resident had actually smoked marijuana in the facility and whether there had been a prior or second incident, with some staff stating they only knew marijuana had been found and removed, and others stating the resident had been caught smoking. The administrator stated that the resident had marijuana removed one day and was smoking the next morning, and that an involuntary transfer form was completed. The resident later reported feeling overwhelmed and attacked by the presence of multiple staff in the room, denied smoking or touching the marijuana, and stated there were no alternatives presented, leading to an emotional outburst. These actions and documentation show that the resident was discharged home the same day for policy non-compliance and behavior, without evidence in the record that the discharge planning ensured a safe and orderly transfer consistent with the resident’s needs and required assistance.
Incomplete Grievance Resolution Documentation
Penalty
Summary
The facility failed to make prompt efforts to resolve resident grievances for 1 of 1 facility reviewed for grievances. The facility’s 1/7/25 Grievance Program policy required prompt efforts to resolve grievances and a recordkeeping system documenting the grievance receipt date, summary statement, investigation steps, pertinent findings or conclusions, whether the grievance was confirmed or not confirmed, and the decision date. A review of grievances from 7/2025 through 11/2025 identified six grievance forms with incomplete documentation showing the grievances were resolved. During an interview on 12/18/2025 at 1:39 PM, the Administrator stated the grievance process was to complete a Concern and Comment card, submit it to the Social Services Director, conduct an investigation, and then have the Administrator sign off once all steps toward resolution were finished; she said the investigation was considered closed after her signature. The Administrator reviewed the six incomplete grievances and confirmed the documentation toward resolution was incomplete.
Hand Hygiene Not Performed During Meal Service
Penalty
Summary
Provide and implement an infection prevention and control program. The facility failed to ensure proper hand hygiene was completed during meals for 1 of 1 dining room reviewed for dining, which placed residents at risk for cross contamination. The facility’s 10/28/25 Hand Hygiene Policy and Procedure states that associates must perform hand hygiene before and after contact with the resident, after contact with blood, body fluids or visibly contaminated surfaces, and after contact with objects and surfaces in the resident’s environment. On 12/18/25 at 12:11 PM, Staff 20, a CNA, was observed in the dining room delivering a lunch tray to a resident, removing lids from bowls, cutting up items on the plate, touching the resident’s shoulder, and asking if the resident needed anything else. While waiting for another lunch tray to be prepared, Staff 20 touched her face, twirled her hair, and adjusted her clothing. Staff 20 then retrieved another lunch tray and delivered it to a resident. At 12:20 PM, Staff 20 stated she was uncertain when she was supposed to complete hand hygiene and acknowledged she did not sanitize her hands between delivery of the lunch trays and touching other surfaces. At 12:40 PM, Staff 2, the DNS, stated she expected staff to complete hand hygiene before entering and leaving a room, in the dining room, in between handing out trays, and when staff were in contact with residents or their environment.
Failure to Inform Residents of Risks and Benefits for Psychotropic Medications
Penalty
Summary
The facility failed to provide information regarding the risks, benefits, and side effects of psychotropic medications before administration for 2 of 5 sampled residents reviewed for medications. One resident was admitted with fibromyalgia and had a quarterly MDS showing cognitive intactness with a BIMS score of 13. That resident’s physician order included amitriptyline 50 mg at bedtime, started on 10/21/25, but there was no evidence in the health record that the resident was informed of the risks and benefits of amitriptyline before it was given. On 12/17/25, the resident was unable to recall details of his or her medications, and on 12/18/25 the LPN Resident Care Manager confirmed there was no evidence the resident had been provided the risks and benefits for amitriptyline. A second resident was admitted with diagnoses including anxiety and diabetes and had physician orders for sertraline 50 mg daily and trazodone 25 mg at bedtime. MAR review showed sertraline had been administered daily since 6/6/25 and trazodone nightly since 9/16/25. The medical record contained no documentation that the resident was informed of the risks and benefits for sertraline and trazodone before administration. On 12/19/25, the DNS confirmed the resident was not provided the risk and benefits for use of sertraline and trazodone.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the State Agency within two hours for one of two sampled residents reviewed for abuse. Resident 52 was admitted in 11/2024 with diagnoses including anxiety and adult failure to thrive, and an 11/4/25 annual MDS showed a BIMS score of 14, indicating no cognitive impairment. Resident 52 died in the facility on 11/25/25. On 12/18/25, Staff 16, a CNA, stated she witnessed Staff 17, a CNA, showing pictures of Resident 52's genitals to Staff 18, a CNA, on Staff 17's personal cell phone. Staff 16 said the incident occurred in 11/2025 and that she reported it to the Administrator the following Monday. No evidence was found that the allegation was reported to the State Agency. The Administrator and DNS initially stated they were unaware of any abuse allegation related to Resident 52, and later learned that the Staffing Coordinator had been aware of the allegation in 11/2025 but it was not reported. The Staffing Coordinator stated Staff 16 told her about the incident and she instructed Staff 16 to report it to the Administrator immediately, but she did not follow up to confirm the allegation was reported.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to notify two residents in writing of the reason for transfer to the hospital. Resident 8, admitted with diagnoses including bipolar disorder and diabetes, was transferred to the hospital due to confusion and unrelieved pain and later re-admitted with septic arthritis in the right hip; the medical record contained no indication that the resident was notified in writing of the reason for the hospital transfer, and the DNS stated the resident was not notified in writing. Resident 66, admitted with pneumonia, experienced a change of condition and was sent to the hospital, but the medical record showed no indication that a written Notice of Transfer was issued to the resident or the resident representative; an LPN stated she did not issue the notice when the resident was sent to the hospital and was not aware it was required.
Failure to Provide Restorative Therapy
Penalty
Summary
The facility failed to ensure restorative therapies were provided for one resident reviewed for rehab services and falls. The resident was admitted with diagnoses including a right leg fracture and sepsis, and the admission MDS dated 9/23/25 showed a BIMS score of 15, indicating no cognitive impairment. On 12/15/25, the resident stated that restorative services were supposed to continue after skilled therapy ended, but staff had not walked with the resident or done exercises for several weeks. During interviews, a CNA stated the facility had two restorative aides who completed all restorative therapies and said she did not do any exercises or ambulation with the resident. Another CNA also stated restorative aides completed all restorative programs. A unit care coordinator later stated the resident's restorative program was completed by CNAs and there were no restorative aides in the facility. The DNS stated she expected CNAs to read the care plan before each shift and follow the care plan related to the restorative program.
Failure to Follow Medication and Wound Care Orders
Penalty
Summary
The facility failed to follow physician orders for Resident 24 and Resident 45. Resident 24 was admitted with diagnoses including chronic pulmonary embolism and diabetes, and had a 6/5/25 order for Eliquis 5 mg by mouth twice daily. The 12/2025 MAR showed the 8 AM dose was not given on 12/11/25, 12/12/25, and 12/13/25 and was coded as “Other/See Progress Note” by an LPN. Progress notes for those dates only documented that Eliquis was on order, with no further information. The LPN stated she would notify the pharmacy and physician and check the Omnicell if a resident was out of medication, but she did not recall checking the Omnicell for Resident 24’s Eliquis on those dates. The DNS stated Eliquis was available in the Omnicell and that she was not notified of the missed doses; the Omnicell transaction report showed Eliquis was dispensed from the Omnicell on 12/12/25 and 12/13/25, confirming the medication was on hand. Resident 45 had a 12/3/25 physician order for wound care to the right shin every three days. The 12/2025 MAR documented wound care on 12/12/25 and 12/15/25, but the resident’s right shin dressing was observed on 12/15/25 and 12/16/25 with “12/8” written on it. The resident stated the wound was last changed on the date written on the dressing. An LPN confirmed the wound care was scheduled every three days and that the current dressing dated 12/8 needed to be completed. One LPN stated she did not recall whether she changed the dressing as scheduled on 12/12/25, and another LPN stated she saw that the 12/15/25 wound care was not completed and did not recall whether she asked another nurse to do it.
Unnecessary Antibiotic Use for Suspected UTI
Penalty
Summary
The facility failed to ensure an antibiotic was indicated for use for one resident reviewed for medications. The facility’s Antibiotic Stewardship Policy stated it should follow the McGeer Criteria before starting antibiotics, and the Revised McGeer Criteria for UTI without an indwelling catheter required at least one sign or symptom such as discomfort, fever, leukocytosis, hematuria, or increased incontinence, urgency, or frequency. Resident 5 was admitted with diagnoses including fibromyalgia, and the record for 11/15/25 through 12/1/25 showed no urinary complaints, including discomfort, fever, leukocytosis, hematuria, or increased urgency, frequency, or incontinence. The resident’s record showed a UA was collected on 12/1/25, but there was no corresponding physician order for the test. The UA final result was positive for leukocytes, nitrites, protein, blood, and two or more types of bacteria, and there was no evidence that a sensitivity test was completed to identify an appropriate antibiotic. A physician order on 12/4/25 started nitrofurantoin 100 mg by mouth twice daily for 10 days for UTI. The Medical Director reviewed the UA and stated it supported the need for a culture and sensitivity test, and the DNS confirmed there was no documentation of urinary complaints leading up to the UA and acknowledged the lack of a physician order for the test.
Ordered TSH Lab Not Drawn
Penalty
Summary
The facility failed to ensure lab services were provided when ordered for one resident who had diagnoses including diabetes and anxiety and was receiving thyroid replacement medication. A pharmacy recommendation on 12/4/25 noted that a TSH laboratory test within the last year was not located in the resident’s medical record. On 12/10/25, the physician ordered a fasting lipid panel, TSH, and serum magnesium concentration, and the TAR showed the lab draw task was completed that morning. However, the 12/11/25 lab results included the lipid panel and magnesium results but no TSH result, and the resident’s record contained no indication of a TSH lab result. On 12/18/25, Staff 4 confirmed the TSH lab was not drawn and stated it should have been drawn with the other ordered labs.
Failure to Prevent Accidents and Update Care Plans
Penalty
Summary
The facility failed to ensure the safety of residents and update care plans following accidents, as evidenced by incidents involving three residents. Resident 21, who has left side paralysis and moderate cognitive impairment, fell from a mechanical lift due to the failure of CNAs to attach required safety clips, resulting in a fractured arm and hospitalization. The CNAs involved did not receive updated training on the use of mechanical lifts, contributing to the accident. Resident 36, diagnosed with Parkinson's disease and at risk for falls, experienced multiple falls due to inadequate supervision and failure to implement care plan interventions. Observations revealed that the resident's wheelchair was often not within reach or locked, and investigations into the falls lacked critical information such as the timing of the last visual check or toileting assistance. Additionally, the care plan was not updated with new interventions, and neurological checks post-fall were incomplete. Resident 48, with a history of falls and a diagnosis of chemical imbalance affecting the brain, also experienced multiple falls. The care plan was not updated with new interventions following these incidents, despite staff instructions to place fall mats and keep the bed in the lowest position. The facility's failure to update care plans and implement necessary interventions contributed to the continued risk of falls for these residents.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, resulting in unresolved severe pain. Resident 41, who was admitted with a pressure ulcer and chronic pain syndrome, did not receive their prescribed oxycodone for five days due to the facility's failure to order medications in a timely manner. Despite having access to an emergency medication cart, the staff did not obtain the necessary code to access the medication. As a result, Resident 41 experienced severe pain that prevented them from performing usual daily activities, and it took two days after receiving the medication for their pain to return to baseline levels. Similarly, Resident 52, admitted after spinal surgery, did not receive their prescribed oxycodone on the day of admission, despite reporting severe pain. Although the pharmacy authorized the removal of oxycodone from the emergency supply, the staff did not administer the medication, leading to the resident being sent to the emergency room for pain management. There was also a lack of documentation regarding the resident's pain medication and the rationale for not administering it, highlighting a deficiency in the facility's pain management practices.
Failure to Post Accessible and Accurate Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a location easily accessible to residents and visitors, and also failed to post accurate and complete staffing information for several days. On 9/23/24, the Direct Care Staff Daily Report was observed to be posted above standing eye level on a wall behind the nurse's station counter, making it difficult to see. On 9/24/24, the report was not filled out for the evening shift, and on 9/26/24, it was posted without any data. A review of the reports from 8/12/24 through 9/26/24 revealed missing census data for the evening shift on 8/31/24 and missing nursing hours for the night shift on 9/16/24. Staff 34, the Staffing Coordinator/Admissions Coordinator, acknowledged the hard-to-see location and the missing data for the identified dates.
Failure to Implement Enhanced Barrier and Transmission-Based Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions for two residents with wounds, placing them at risk for cross-contamination. Resident 3, admitted with rib fractures, was observed with scabs and a wound dressing on the right shin, but their room was not identified for EBP. Staff 25, an LPN, confirmed that Resident 3 was not on the daily list of residents requiring EBP, despite the Director of Nursing Services (DNS) stating that residents with wound care should be on EBP. Resident 9, admitted with a leg fracture, had a sign indicating EBP and droplet precautions, requiring staff to wear a mask and gown. However, Staff 27, a physical therapist, was observed wearing only gloves without a mask or gown. The DNS confirmed the requirement for masks and gowns, but Staff 27 stated they were not notified of the droplet precautions and did not see the sign.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually, as evidenced by the review of training records for five out of six staff members. Specifically, one CNA hired in May 2018 had only 10 hours and 46 minutes of training documented, while another hired in May 2022 had just five hours and 36 minutes. A CNA hired in August 2023 had no documented training, and two others hired in March 2018 and April 2022 had less than six hours of training each. The Director of Nursing Services (DNS) acknowledged the deficiency, noting that competency evaluations were conducted upon hire and annually, with in-service training provided during staff meetings and through internet-based services. However, the records did not reflect the completion of the required training hours.
Failure to Include Resident's Guardian in Care Planning
Penalty
Summary
The facility failed to ensure that residents were included in the care planning process, specifically for a resident diagnosed with autism who was admitted in July 2022. The resident's responsible party and guardian, identified as a family member, was not consistently invited to care conferences. Documentation revealed that the last recorded care conference involving the guardian was in October 2023. Subsequent notes from May 2023 and July 2024 did not indicate that the guardian was invited or attended any care conferences. The guardian confirmed not being invited to a care conference for a significant period, which was corroborated by the facility's staff list showing a new Social Services Director hired in April 2024. Despite efforts by facility staff to find additional documentation, no evidence was provided to show the guardian's involvement in care planning since October 2023.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' current advance directive information was accurately reflected in their clinical records, affecting three out of five sampled residents. Resident 3, who was admitted with rib fractures and was cognitively intact, had a care plan indicating the presence of an advance directive. However, the clinical record did not include a copy of this directive. Despite the resident's confirmation of having an advance directive and the Social Service Director's acknowledgment of the care plan's indication, no follow-up was conducted to obtain the document for the clinical record. Similarly, Resident 45, admitted with diabetes and left-sided weakness, had no advance directive documented in their medical record, nor was there any indication that one was offered or refused. The Social Services Director confirmed the absence of documentation regarding the offering of an advance directive. Resident 51, with chronic obstructive pulmonary disease and a surgical amputation, also lacked an advance directive in their medical chart. Although a facility form indicated that information about an advance directive was provided, there was no follow-up documentation. The Social Services Director acknowledged the lack of follow-up for the advance directive previously offered.
Failure to Notify Resident's Representative of Hospitalization
Penalty
Summary
The facility failed to notify a resident's representative of the resident's hospitalization, which was a deficiency identified during the survey. Resident 33, who was admitted to the facility in April 2023 with a diagnosis of dementia, experienced a change in condition and was transported to the hospital for evaluation and treatment on August 17, 2024. Despite Witness 6 being listed as the first emergency contact for Resident 33, there was no documentation indicating that Witness 6 was informed of the hospitalization. This lack of notification was confirmed during an interview with Witness 6 on September 23, 2024, and further corroborated by the absence of documentation when requested from Staff 24, an LPN, on September 25, 2024.
Failure to Notify Responsible Party of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide written notification regarding a change in Medicare coverage for a resident, identified as Resident 9, who was reviewed for Medicare notification of non-coverage. Resident 9, who was admitted with a diagnosis including a fracture of the left leg, had a BIMS score of 9, indicating moderate cognitive impairment. A Notice of Medicare Non-Coverage (NOMNC) form was signed by Resident 9, but there was no documentation that the responsible party was contacted or informed about the form, the effective date when Medicare would no longer cover skilled nursing services, or the process to appeal the decision. The deficiency was further highlighted during interviews with staff and the resident's family member. The family member, who was the responsible party, stated that the facility did not contact her regarding the NOMNC form, despite being aware of her role. Staff members, including the Social Services Director and Business Office staff, acknowledged that the protocol for cognitively impaired residents was to notify and have the family representative present during the signing of the form. However, the staff failed to review the resident's clinical record to identify the responsible party, leading to the oversight.
Facility Fails to Maintain Safe and Homelike Environment Due to Uneven Floors
Penalty
Summary
The facility failed to maintain a safe and homelike environment for two residents, resulting in an unsafe and unhomelike living condition. Resident 11, who was admitted with vertigo and unsteadiness, reported that the floor in their room was so uneven that furniture would roll across the room. This was confirmed by an observation of a visible slope in the room. Resident 20, admitted with muscle weakness and unsteadiness, also experienced similar issues, requesting blocks under their bed to level it. Staff confirmed the unevenness, noting that the building appeared to have a U shape from the outside. Staff interviews revealed that the maintenance director acknowledged the problem and stated that an external company would be brought in to assess the situation. A CNA expressed concern about the uneven floors, indicating a risk of losing balance. The regional president and nurse confirmed that inspections were conducted and plans were made to move affected residents to other rooms. However, no structural damage was reported at the time of the interviews.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by staff. Resident 56, who was admitted with diagnoses including kidney disease and diabetes, and had moderate cognitive impairment, was involved in an incident with Staff 15, an agency LPN. On the night shift, Staff 15 reportedly became upset when Resident 56 pushed a bedside table into him. In response, Staff 15 allegedly grabbed the resident's bed covers, pushed down on the resident's chest, and sternly warned the resident not to repeat the action. This incident was later reported by the resident, who expressed fear about mentioning it. Witnesses, including a family member and other staff, corroborated the account of Staff 15's aggressive behavior. Staff 15 admitted to being loud and stern with the resident and expressed anger during the incident. Despite these reports, the facility did not conduct an investigation into the alleged abuse. Staff 3, a regional president, dismissed the incident as non-abusive, citing the resident's cognitive status and lack of self-reported abuse. However, the absence of an investigation and missing documentation of the incident highlight a deficiency in the facility's handling of abuse allegations.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment, diagnosed with kidney disease and diabetes, to the State Survey Agency. The incident occurred when an agency LPN, identified as Staff 15, allegedly had a physical altercation with the resident during the night shift. Staff 15 reportedly bragged about the incident, where the resident pushed a bedside table into him, prompting him to grab the resident's bed covers and push down on the resident's chest. The resident expressed fear about the incident, which was later reported to the family. Despite the seriousness of the allegation, there was no documentation indicating that the facility reported the incident to the State Survey Agency. Interviews with staff and family members corroborated the occurrence of the incident, with Staff 15 admitting to being stern and loud with the resident. The facility's administration, including the Director of Nursing Services and regional management, stated that they expected such allegations to be reported to the appropriate authorities, yet this protocol was not followed in this case.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with moderate cognitive impairment, diagnosed with kidney disease and diabetes. The incident occurred when an agency LPN reportedly had a negative interaction with the resident, which included the LPN allegedly pushing down on the resident's chest after the resident pushed a bedside table into the LPN. The resident expressed fear about the incident, and the family was notified. Despite the seriousness of the allegation, there was no documentation indicating that the facility conducted an investigation into the matter. Interviews with staff and family members corroborated the occurrence of the incident, with multiple staff members acknowledging the LPN's actions and the resident's reaction. The facility's administration, including the Director of Nursing Services and regional staff, expected such allegations to be reported to the State Survey Agency and law enforcement. However, no investigation was documented, and the facility did not provide any evidence of having addressed the incident appropriately.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for three residents, which placed them at risk for unmet care needs. Resident 3, admitted with fractured ribs, was observed with a wound dressing on the right shin, which had been present for at least a month. Despite this, the care plan initiated in July was not revised to address the shin wound. Staff acknowledged the oversight in updating the care plan to include the skin issue. Resident 43, admitted with kidney disease and a left hand contracture, was dependent on staff for assistance with a soft hand roll. However, the care plan initiated in February was not updated to reflect this need for assistance. Similarly, Resident 9, admitted with sepsis and diabetes, was at risk for pressure injuries and had a left ankle wound requiring specific care. The care plan, revised in September, lacked goals or interventions for the ankle wound, and staff acknowledged the failure to update the care plan properly.
Failure to Provide Shaving Care for Resident
Penalty
Summary
The facility failed to provide adequate shaving care for a resident who was unable to perform activities of daily living independently. The resident, admitted in February 2024 with a diagnosis of stroke, was cognitively impaired but able to communicate needs and required assistance for most ADLs. Observations on September 23 and 24, 2024, revealed the resident had long facial hair, despite expressing a preference for no facial hair. A family member confirmed this preference. A CNA stated that residents were typically shaved on shower days but was unsure why the resident had not been shaved, acknowledging that the resident's facial hair had likely not been attended to for several days.
Failure to Provide Care for Skin Injury and Procedure Preparation
Penalty
Summary
The facility failed to provide appropriate care for a non-pressure skin injury and did not adequately prepare a resident for a medical procedure, affecting two residents. Resident 3, who was admitted with heart disease, had a wound on the right shin that was not properly assessed or treated. The wound was observed to have been present for at least a month, with scabs noted on two separate occasions. However, the clinical record lacked documentation of measurements, assessments, or treatment orders for the wound, and the care plan was not updated to address this issue. It was later discovered that the resident's walker caused friction, leading to the injury, and staff adjusted the walker to prevent further harm. Resident 21, admitted with a stroke diagnosis, was not prepared for a scheduled sigmoidoscopy procedure, which required bowel preparation. Despite hospital discharge orders indicating a follow-up with a general surgeon, the resident was transported for the procedure without the necessary preparation, resulting in a delay. The resident had multiple emergency room visits for bleeding, and the lack of preparation for the diagnostic procedure was acknowledged by the Director of Nursing Services. No additional information was provided regarding this concern.
Failure to Provide Treatment for Hand Contractures
Penalty
Summary
The facility failed to provide appropriate treatment for a resident's hand contractures, which was identified during a survey. The resident, admitted in April 2023 with Parkinson's disease, was noted to have contractures in the third and fourth fingers of both hands. Despite the resident's ability to communicate needs and occasional confusion, there was no treatment plan in place to address the contractures. A family member was unaware of any range of motion (ROM) exercises being provided, and the Director of Nursing Services (DNS) confirmed the absence of a treatment plan for the contractures.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide adequate urinary catheter care and incontinent care for a resident with an indwelling catheter, leading to unmet urinary catheter needs and potential risk for urinary tract infections. The resident, who was admitted with diagnoses including retention of urine and acute kidney failure, had a care plan that required catheter care every shift and monitoring for signs of urinary tract infections. However, documentation revealed inconsistencies in catheter changes and monitoring of urine output. On multiple occasions, there was no documentation of urine output, and the resident experienced significant pain due to a clogged catheter, which was not promptly addressed by the staff. The resident was in pain for an extended period, and despite complaints of bladder pain, the staff did not perform a timely assessment or catheter change. The resident's pain was only relieved after a catheter change was performed by a different staff member during the night shift, resulting in a significant release of urine. Interviews with staff indicated a lack of proper assessment and documentation, with one staff member admitting to not remembering performing a bladder scan or assessment for the resident's pain and lack of urine flow. This deficiency highlights a failure in the facility's catheter care protocol and documentation practices.
Failure to Follow Nutritional Care Plan for Resident with Parkinson's
Penalty
Summary
The facility failed to adhere to the nutritional care plan for a resident diagnosed with Parkinson's disease and mental health disorders, who was at nutritional risk and had difficulty swallowing. The resident was admitted in April 2023 and had a care plan that included providing snacks twice daily (BID) to prevent weight loss. However, there was no documentation indicating that the resident received these scheduled snacks. On September 26, 2024, the Director of Nursing Services (DNS) acknowledged that the task for providing snacks was not correctly entered into the system, and the Certified Nursing Assistant (CNA) task list only included meal intake. A CNA confirmed that scheduled snacks should be documented if provided, but this was not done for the resident in question.
Failure to Implement Non-Pharmacological Interventions and Document Medication Rationale
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were provided before administering medications and did not document a rationale for not implementing a gradual dose reduction for a resident with dementia. The resident was admitted with a diagnosis of dementia and was prescribed multiple antidepressants, including venlafaxine, amitriptyline, citalopram, and mirtazapine. A pharmacy consultation recommended tapering and discontinuing citalopram, which was accepted, and suggested a gradual dose reduction for venlafaxine. However, the physician declined the dose reduction for venlafaxine, citing the resident's difficulty in adjusting to their medical condition, without providing a documented rationale. Additionally, the resident was prescribed Ativan PRN for anxiety, which was administered multiple times without documented evidence of behaviors or non-pharmacological interventions being attempted prior to its use. The facility's Director of Nursing Services (DNS) was unable to provide documentation of non-pharmacological interventions being used before administering Ativan on the specified dates, indicating a lack of adherence to the facility's protocol for managing anxiety with non-pharmacological methods before resorting to medication.
Failure to Obtain Blood Sample for Laboratory Test
Penalty
Summary
The facility failed to ensure a blood sample was obtained for a resident who was admitted in April 2023 with a diagnosis of a stroke. According to the Treatment Administration Record (TAR) from July 2024, staff were instructed to obtain a blood sample for blood chemistry on July 10, 2024. However, the resident's record did not contain the blood chemistry results. On September 25, 2024, a request was made to the Director of Nursing Services (DNS) and a Licensed Practical Nurse (LPN) to provide the laboratory results, but no additional information was provided. This failure placed residents at risk for delayed treatment.
Failure to Offer Dental Appointment
Penalty
Summary
The facility failed to ensure a resident was offered a dental appointment, which was identified as a deficiency. Resident 3, who was admitted in July 2024 with rib fractures, was noted to have missing, broken, or decaying teeth according to a nutritional assessment. Despite being cognitively intact and initially assessed with no dental issues, the resident later reported having cavities and missing bottom front teeth. The resident stated that the facility did not inquire about scheduling a dental appointment. Staff 4, the Social Service Director, was not informed of the resident's dental concerns, and Staff 2, the DNS, acknowledged that although dental issues were identified, there was no follow-up with the resident.
Inappropriate Antibiotic Use and Monitoring
Penalty
Summary
The facility failed to ensure antibiotics were used appropriately and to monitor antibiotic usage for a resident with a urinary catheter or UTI. The resident, who was admitted with a chemical imbalance affecting the brain and a history of falls, experienced two falls and was sent to the hospital, returning with a UTI diagnosis. A urine analysis showed cloudy urine with bacteria, but no urine culture was initially conducted to determine the appropriate antibiotic. The resident was prescribed Cephalexin, an antibiotic, without confirmation of its effectiveness against the bacteria. Subsequent urine culture results revealed that the bacteria were resistant to Cephalexin, and Meropenem was the only effective antibiotic. Despite this, Cephalexin was not discontinued when Meropenem was started, leading to both antibiotics being administered simultaneously. The Director of Nursing Services acknowledged the inappropriate administration of Cephalexin without proper indication and the failure to discontinue it when Meropenem was initiated.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 24 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Coos Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Coos Bay | 1.5 mi | ★★★★★ | 0 | 0 |
| Aidan Senior Living At Reedsport | 22.4 mi | ★★★★★ | 0 | 0 |
| Myrtle Point Rehabilitation & Care | 22.5 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.