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 Coquina Center during CMS and state inspections, most recent first.
Failure to Preserve Resident Dignity During Meal Assistance: Staff referred to two residents as feeders and were observed standing over residents while feeding them in bed. A CNA and an LPN identified residents as needing meal assistance, and record review showed severe cognitive impairment for two residents, with diagnoses including dementia, anorexia, CHF, and COPD.
A resident with an indwelling urinary catheter and severe cognitive impairment was repeatedly observed in bed with the urinary drainage bag resting on the floor, despite physician orders for proper catheter management and a care plan identifying risk for UTI and requiring appropriate positioning of the bag and tubing. The CNA providing care acknowledged that catheter bags should not touch the floor but confirmed that the bag was on the floor during observation, attributing this to the bed being in a low position. The facility’s catheter care policy, which specifies that the drainage spigot must not touch the floor and that the catheter be maintained at an appropriate level, was not followed.
A resident was emergently transferred after aggressive behaviors and an involuntary emergency psychiatric evaluation, but the facility did not send the transfer/discharge notice with the reason for transfer to the Ombudsman. The DON and Administrator gave conflicting explanations about the transfer, and the Ombudsman only received a monthly discharge report that did not identify the psychiatric evaluation reason.
Incomplete PASRR Screening for Two Residents: The facility failed to ensure PASRR forms were accurate and complete for two residents with significant psychiatric and cognitive histories. One resident had brief psychotic disorder, MDD, insomnia, and severe cognitive impairment, while the other had encephalopathy, dementia, delusions, mood and anxiety disorders, and behavioral issues; both PASRR Level I forms had incomplete screening decision making, and one resident’s screen indicated a Level II PASRR was needed.
Failure to check gastric residual volume occurred for a resident with a g-tube, quadriplegia, protein-calorie malnutrition, metabolic encephalopathy, and expressive language disorder. An LPN administered Jevity 1.5 via pump, flushed the tube, and started the feeding without reviewing the physician’s orders first or checking residual as ordered. The LPN stated she forgot to check the residual, and the DON confirmed staff should review orders before administering enteral nutrition.
Failure to Preserve Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that three residents reviewed for dignity were able to exercise their right to dignity during meal assistance. Staff referred to two residents as feeders, and staff were observed standing over residents while assisting them with meals. On 2/23/26, a CNA was observed in one resident's room assisting with lunch while the resident lay in bed and the CNA stood over her feeding her from the lunch tray for five minutes. During the observation, the CNA stated the resident was a feeder but also said she did not usually feed residents and was not sure whether the resident normally required meal assistance. On 2/25/26, another CNA was observed in the same resident's room assisting with lunch while the resident lay in bed and the CNA stood over her feeding her from the lunch tray for five minutes; the CNA stated she had annual training on assisting residents with meals and that she stood when feeding a resident at bedside. On 2/24/26, an LPN stated that another resident's breakfast tray had been removed from the room and reported that the CNA said the resident ate a few bites of breakfast and drank some juice. The LPN stated the resident was an assisted feeder. A record review showed that the resident had severe cognitive impairment with a BIMS score of 5 and diagnoses of CHF and COPD. Also on 2/24/26, a CNA was observed in a third resident's room assisting with lunch while the resident lay in bed and the CNA stood over her feeding her from the lunch tray for seven minutes. The record review for the first resident showed severe cognitive impairment with a BIMS score of 6 and diagnoses of dementia and anorexia.
Failure to Maintain Urinary Catheter Bag Off the Floor
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that a resident’s indwelling urinary catheter drainage bag was kept off the floor, as required by facility policy and the resident’s care plan. On multiple observations over several days, the resident was seen lying in bed with the urinary catheter bag positioned on the door side of the bed and resting on the floor, with photographic evidence obtained on several of these occasions. The resident had diagnoses including an encounter for fitting and adjusting a urinary device, an active physician order for an indwelling urinary catheter with instructions to use a catheter tube securing device and adjust its position as needed, and a care plan identifying the resident as at risk for urinary tract infection related to incontinence and the presence of an indwelling catheter, with an intervention to position the catheter bag and tubing to promote dignity and drainage. During an interview, the CNA responsible for the resident’s care stated that catheter care involved ensuring there were no kinks in the tubing, emptying the bag, and reporting output to the nurse, and acknowledged that the urinary drainage bag should not touch the floor. When asked to observe the resident’s catheter bag while it was resting on the floor, the CNA confirmed that it was on the floor and explained that sometimes when beds are in a low position, the bags will touch the floor. The resident’s quarterly MDS showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. The facility’s catheter care policy required that the drainage spigot not touch the floor, that tubing be free of kinks, and that the catheter be kept at an appropriate level to promote urine flow and maintain dignity, which was not followed in this case.
Failure to Send Transfer Notice to Ombudsman
Penalty
Summary
The facility failed to send a copy of the transfer/discharge notice to a representative of the Office of the State Long-Term Care Ombudsman for one resident who was emergently transferred from the facility. Record review showed the resident was transferred on 1/8/26 after staff documented aggressive behaviors toward staff and the arrival of police and emergency medical transport. A nursing note stated the resident was assisted onto a stretcher and transported to a local hospital. During interviews, the DON initially stated the resident had been emergently transferred by police and that this did not fall under the facility, then later acknowledged that emergency medical transport moved the resident and that police transport would not have been appropriate. The Administrator stated the Ombudsman’s office had been notified through a monthly discharge report, but the report did not include the reason for transfer. When asked for verification that the reason for transfer had been sent, she produced a Nursing Home Transfer and Discharge Notice dated 1/8/26 stating the reason for discharge or transfer was that the resident’s needs could not be met in the facility, with a brief explanation referencing an involuntary emergency psychiatric evaluation for safety concerns. The Administrator later confirmed that this transfer form was not sent to the Ombudsman’s office and that the office was only sent the monthly discharge report. The Ombudsman stated her office was aware the resident had been transferred to a local hospital, but was not informed that the resident had been sent out for an involuntary emergency psychiatric evaluation. The facility policy titled Transfers and Discharges stated that a copy of the transfer notice will be sent to the Office of the State Long-Term Care Ombudsman.
Incomplete PASRR Screening for Two Residents
Penalty
Summary
The facility failed to review the accuracy and completion of the PASRR forms for two residents. One resident was admitted with diagnoses including brief psychotic disorder, recurrent major depressive disorder, insomnia, and signs and symptoms involving cognitive functions and awareness, and had an active order for escitalopram related to major depressive disorder. The resident’s care plan identified impaired cognitive function and impaired thought processes related to brief psychotic disorder and cognitive symptoms, and a psychiatric progress note listed a history of MDD, dementia, mood disorder, psychosis, and insomnia. The resident’s PASRR Level I form dated 7/23/24 had Section 1 screening decision making not completed. The second resident was admitted with diagnoses including encephalopathy, mental disorder, delusional disorders, dementia, psychotic disturbance, mood disturbance, brief psychotic disorder, anxiety disorder, recurrent major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. The care plan documented a history of behaviors including non-compliance with smoking policy and medical care, refusal of medications, calling 911, verbal aggression, and hoarding cups, along with impaired cognitive function and impaired thought processes related to encephalopathy, dementia, AMS, confusion, delusions, and psychiatric disorders. The resident’s PASRR Level I form dated 2/18/26 also had Section 1 screening decision making not completed, and Section II indicated yes for interpersonal functioning concerns; Section III noted the screen was not a provisional admission, so a Level II PASRR should have been completed.
Failure to Check Gastric Residual Before Tube Feeding
Penalty
Summary
Failure to check gastric residual volume occurred for one resident receiving enteral nutrition through a gastrostomy tube. The resident had an admission date of 12/2/25 and diagnoses including quadriplegia, protein-calorie malnutrition, gastrostomy status, metabolic encephalopathy, and expressive language disorder. Physician orders included Jevity 1.5 at 75 ml per hour for 18 hours a day, 60 ml water flushes every hour while feeding was in progress, NPO status, and checking residual every shift with instructions to hold feeding and notify the physician if residual was greater than 60 ml. The care plan also directed staff to check tube placement and gastric contents/residual volume and record it. On 2/25/26 at 3:56 pm, an LPN was observed administering tube feeding to the resident. She performed hand hygiene, donned gown and gloves, hung the Jevity 1.5, primed the tubing, flushed the g-tube with 60 ml of water, connected the feeding, and started the pump at 75 ml per hour. She did not review the physician's orders before beginning the feeding and did not check for gastric residual prior to connecting the feeding. When asked about it, she stated she forgot and should have checked the residual first. On 2/26/26, the DON stated the LPN notified her of the enteral feeding concern and confirmed that nursing staff should review physician orders prior to administering medication or enteral nutrition to ensure they are given as ordered.
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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.
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Nursing homes near Ormond Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgeview Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Ormond Rehabilitation And Nursing Center | 1.6 mi | ★★★★★ | 29 | 0 |
| Avante At Ormond Beach, Inc | 2.8 mi | ★★★★★ | 0 | 0 |
| Terrace At Bishop's Glen, The | 3.5 mi | ★★★★★ | 0 | 0 |
| Daytona Beach Health And Rehabilitation Center | 4.6 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.