Map showing the location of AVAMERE REHABILITATION OF COOS BAY in COOS BAY, Oregon
2625 KOOS BAY BLVD, COOS BAY, OR, 97420

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • OregonAbove only 17% of peers127 rated homes · average 3.0★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs OR avg
  • StaffingCan add or remove a star4★+0.3 vs OR avg
  • Quality measuresCan add or remove a star3★−0.5 vs OR avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 18% of peersOR avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 31% of peersOR avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 15% of peersOR avg3.5★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.54hrsAbove only 21% of peersOR avg4.95Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.52hrsAbove only 36% of peersOR avg0.68Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better34%Above 84% of peersOR avg49%RN turnover43%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$15,593Above only 44% of peersOR avg$32,647Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
45citations
4inspection dates
1actual harm (G–I)
2immediate jeopardy (J–L)
Aug 25, 2025most recent

Citations by monthMar 2023 – Aug 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Aug 25, 202517 citationsCycle 1worst G · actual harm
  1. F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Resident RightsD · isolatedCorrected Sep 11, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Sep 11, 2025
  3. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Sep 11, 2025
  4. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Sep 11, 2025
  5. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Sep 11, 2025
  6. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Sep 11, 2025
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 11, 2025
  8. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Sep 11, 2025
  9. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 11, 2025
  10. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Sep 11, 2025
  11. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Sep 11, 2025
  12. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceG · isolatedCorrected Sep 11, 2025
  13. F761Ensure 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.Pharmacy ServiceE · patternCorrected Sep 11, 2025
  14. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Sep 11, 2025
  15. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Sep 11, 2025
  16. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 11, 2025
  17. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 11, 2025
May 3, 202413 citationsCycle 2worst F · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 29, 2024
  2. F584Honor 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.Resident RightsD · isolatedCorrected May 29, 2024
  3. F688Provide 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.Quality of Life and CareD · isolatedCorrected May 29, 2024
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 29, 2024
  5. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 29, 2024
  6. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected May 29, 2024
  7. F761Ensure 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.Pharmacy ServiceE · patternCorrected May 29, 2024
  8. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 29, 2024
  9. F840Employ 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.AdministrationD · isolatedCorrected May 29, 2024
  10. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected May 29, 2024
  11. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected May 29, 2024
  12. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 29, 2024
  13. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 29, 2024
Nov 22, 20232 citationsCycle 3worst J · immediate jeopardy$15,593
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningJ · isolatedCorrected Nov 14, 2023
  2. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareJ · isolatedCorrected Nov 14, 2023
Mar 10, 202313 citationsCycle 3worst E · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Apr 14, 2023
  2. F584Honor 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.Resident RightsE · patternCorrected Apr 14, 2023
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 14, 2023
  4. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Apr 14, 2023
  5. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 14, 2023
  6. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Apr 14, 2023
  7. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 14, 2023
  8. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Apr 14, 2023
  9. F803Ensure 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.Nutrition and DietaryD · isolatedCorrected Apr 14, 2023
  10. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 14, 2023
  11. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Apr 14, 2023
  12. F888Ensure staff are vaccinated for COVID-19Infection ControlD · isolatedCorrected Apr 14, 2023
  13. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Apr 14, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.54hrsAbove only 21% of peers−0.41 vs OR avg
  • Registered nursesRN hours only0.52hrsAbove only 36% of peers−0.16 vs OR avg
  • Licensed practical nursesLPN hours0.92hrs
  • Nurse aidesCNA hours3.10hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.82hrs
  • Oregon average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better34%Above 84% of peersOR avg 49%
  • RN turnoverRegistered nurses only43%Not ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy92 certified beds · ~49 residents a day54%Above only 23% of peersOR avg 69%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $15,593In fines
  • 1Fine
  • 0Payment denials
  • $32,647OR avg in fines
Above only 44% of peersFewer fines than 44% of rated homes in Oregon

Actions on record

  1. Nov 22, 2023Civil money penalty$15,593

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Avamere33 facilities in the chain3.0★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Indirect owners (5%+)
  • Karl Miller
Operational or managerial control
  • Avamere Health Services LLC
  • Avamere Skilled Advisors LLC
  • Jeffrey Aronson
  • Kirsten Carr
  • Tonia Clark
  • Jennifer Dana
  • Cody Feakin
  • Nelson Henriquez
  • +9 more
5% Or Greater Security Interest
  • Midcap Finco LLC

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 385239 · 2625 KOOS BAY BLVD, COOS BAY, OR, 97420.
  • Percentiles compare this facility with every rated nursing home in Oregon and Coos County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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