Coquina Center

In the surveyor’s words

From the most serious findings on record at Coquina Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Feb 26, 2026

  Based on observations, interviews and record review, the facility failed to ensure that three (Residents #1, #8 and #20) of three residents reviewed for dignity were able to exercise their right to dignity. Staff referred to Residents #1 and #8 as feeders, and were observed standing over Residents #1, #8 and #20 while assisting them with their meals. The findings include:1.On 2/23/26 at 12:10 PM, Certified Nursing Assistant (CNA) I was observed in Resident #1's room assisting her with her lunch meal. Resident #1 was lying in bed while CNA I stood over her feeding her food from her lunch tray. This observation lasted five minutes. During an interview with CNA I at the time of the observation, she was asked if Resident #1 normally required assistance with her meal. […]

• No harm, potential for more than minimal, isolatedF628Feb 26, 2026

  Based on interviews and record review, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one (Resident #128) of two residents reviewed for transfer/discharge. The findings include: A record review for Resident #128 revealed that the resident had been emergently transferred on 1/8/26. A nursing note dated 1/9/26 at 7:30 AM revealed: Upon coming onto my shift at 11pm, I received in report from the 3-11 nurse that (Resident #128's physician) had come to the facility and initiated customer to being (emergently transferred) related to aggressive behaviors toward staff. […]

• No harm, potential for more than minimal, isolatedF645Feb 26, 2026

  Based on record review and interviews, the facility failed to review the accuracy and completion of the Preadmission Screening and Resident Review (PASRR) forms for two (Residents #70 and #44) of two residents reviewed for PASRR completion. Failure to ensure the accuracy/completion of the residents' PASRRs placed the residents at risk for not receiving needed services.The findings include:1.A review of Resident #70's medical record revealed an admission date of 7/29/24 with diagnoses including brief psychotic disorder, major depressive disorder (MDD) - recurrent, insomnia, and signs/symptoms involving cognitive functions and awareness. […]

• No harm, potential for more than minimal, isolatedF693Feb 26, 2026

  Based on observation, interviews and record review, the facility failed to check gastric residual volume (GRV) for one (Resident #52) of three residents reviewed for enteral nutrition. Failure to check for gastric residual volume can result in accidental inhalation of food/liquid into the airway and lungs instead of the esophagus, which can lead to choking, lung infections and/or breathing difficulty.The findings include:A review of Resident #52's medical record revealed an admission date of 12/2/25 with diagnoses including quadriplegia (paralysis resulting in partial or total loss of function in all four limbs and the torso), protein-calorie malnutrition, gastrostomy (feeding tube) status, metabolic encephalopathy (brain dysfunction causing symptoms like confusion, delirium, tremors… […]

• No harm, potential for more than minimal, isolatedF880Feb 26, 2026

  Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections, by repeatedly failing to ensure that one (Resident #1) of one resident who was reviewed for urinary catheter care, had a urinary catheter bag that was kept off the floor. Failure to ensure a urinary catheter bag remains off the floor can result in a catheter-associated urinary tract infection.The findings include: On 2/23/2026 at 12:10 PM, Resident #1 was observed lying in bed. Her urinary catheter bag was observed on the door side of her bed and was observed to be resting on the floor. […]