Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facilty failed to provide treatment and care in accordance
with professional standards of practice for one (Resident #48) of 39 residents sampled. Resident #48
received no flushes to her Peripherally Inserted Central Catheter (PICC) line.
Residents Affected - Few
The findings include:
A review of Resident #48's medical record revealed she was admitted on [DATE] with a readmission on
[DATE]. The resident was transferred to a hospital on 5/18/22 to have a PICC line removed. The PICC line
was present on the 3/1/22 readmission. Resident #48 was admitted with diagnoses including
encephalopathy, pressure ulcer - stage IV to sacrum, severe sepsis, aphasia, and major depressive
disorder.
A 5/16/22 observation of Resident #48 at 1:59 PM, revealed a left subclavian central line (SCL) with a
transparent dressing covering the insertion site. The date on the dressing was illegible.
On 5/17/22 at 3:48 PM, the left SCL had a transparent dressing covering the insertion site. The site was
clean, dry, and intact. The insertion site was dark pink, and the dressing was dated 5/17/22.
A review of the admission Minimum Data Set (MDS) assessment, dated 3/5/22, revealed under Section O Special Treatments, Procedures, and Programs - Item H: Intravenous (IV) medications yes.
A review of the resident's active Care Plan, revealed a focus area for the administration of IV antibiotics for
the treatment of a sacral wound infection and impaired skin integrity for the care and maintenence of an IV
site. Interventions included: IV dressing, observe dressing every shift change and record observations; labs
as ordered; monitor signs and symptoms of infection at the site - drainage, inflammation, swelling, redness,
warmth; monitor signs and symptoms of leaking at the IV site, edema at the insertion site; monitor site for
signs and symptoms of swelling, redness, pain, and increased temperature.
A review of the resident's orders revealed:
3/1/22, Aztreonam Solution 1 gram, IV every 8 hours related to severe sepsis until 3/14/22. The March 2022
MAR revealed the last dose was given on 3/13/22 at 2:00 PM.
3/1/22 Vancomycin solution 1 gram IV every 18 hours related to severe sepsis until 3/14/22.
3/7/22 Vancomycin solution 750 milligrams in 150 ml (milliliter) normal saline every 12 hours
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
105589
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105589
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coquina Center
170 N Center Street
Ormond Beach, FL 32174
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
related to severe sepsis until 3/14/22.
Level of Harm - Minimal harm
or potential for actual harm
3/1/22 Change IV dressing weekly and as needed when soiled.
Residents Affected - Few
No orders for normal saline flushes or documentation of flushes were found in the resident's medical
record.
A review of assessments and progress notes revealed:
On 3/1/22 at 2:52 PM, Patient transferred into facility via stretcher at 1405 (2:05 PM). Patient alert.
Non-verbal. Skin warm and dry. Tunneled PICC line to left upper chest.
One 3/1/22 Admission/readmission Nursing packet-Sec. IV Infection Risk Evaluation, Item 2a. Appliances tunneled PICC left chest. Sec. XIV Baseline Care Plans, Item 7 - Special treatments/procedures,
subsection d. IV medication was not marked in the affirmative.
3/4/22 Summary of Skilled Services - Currently on IV antibiotics for sepsis.
On 5/18/22 at 10:05 AM, an interview was conducted with the Interim Director of Nursing (IDON). When
asked how long a PICC line could be in place, she stated she was not aware of a time line, but if it was
prophylactic, it could be in place for months. When asked whether the line needed to be flushed, she
replied, If the physician orders flushes. When asked if a physician's order was needed to remove a PICC
line, she replied yes.
On 5/18/22 at 3:15 PM, an interview was conducted with Registered Nurse (RN)/Unit Manager F. When
asked how PICC lines were to be cared for at the facility, she stated the dressing was changed at least
weekly and the line was flushed before and after medication administration. When asked if a PICC line that
was not in use still needed to be flushed, she stated, Yes, otherwise it will clot off.
On 5/19/22 at 10:40 AM, an interview was conducted with the Medical Director. He stated he had been
made aware that Resident #48 needed to go to the hospital to have a PICC line removed. When asked how
these types of lines were handled, he stated, When a resident comes in, the nurses are to inform the
physician of the line. Then the physician will reach out the hospital to find out why the line is in place and
determine a potential removal date.' When asked if this type of line should be flushed when not in use, he
stated, Absolutely, they must be flushed to prevent the lines from clotting off.
A review of the facility's policy on Peripherally Inserted Central Catheters (PICCs) with a revision date of
5/18/2020, stated on page 3, item #13, PICC lines are to be flushed with 3 milliliters (ml) of normal saline
every 12 hours when not in use or as ordered by the provider. Item #14, PICC lines are to be flushed with 3
ml of normal saline before and after the administration of Intravenous (IV) medication solutions.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105589
If continuation sheet
Page 2 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105589
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coquina Center
170 N Center Street
Ormond Beach, FL 32174
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to 1) Ensure that a resident with limited
range of motion received appropriate treatment and services to increase range of motion and/or to prevent
further decrease in range of motion, and 2) Ensure residents received appropriate services, equipment,
and assistance to maintain or improve mobility with maximum practicable independence for one (Resident
#107) of 39 residents sampled.
The findings include:
On 5/16/2022 at 1:00 p.m., Resident #107 was observed with a left hand contracture. During an interview
with the resident at this time he stated he denied having a splint for his left hand, but stated he thought he
needed one and had mentioned this to the staff without success.
A medical record review revealed that Resident #107 was admitted into the facility on 8/22/2021. His last
readmission was on 9/14/2021. His diagnoses included hemiplegia and hemiparesis following cerebral
infarction affecting the left non-dominant side; congestive heart failure; major depressive disorder; cerebral
palsy; anxiety disorder and benign prostatic hyperplasia.
The last three Minimum Data Set (MDS) assessments were reviewed.
Per the admission assessment dated [DATE], the resident had a Brief Interview for Mental Status (BIMS)
score of 15 out of a possible 15 points, indicating intact cognition. He required supervision with eating and
extensive assistance with all other Activities of Daily Living (ADLs). He was noted with limited range of
motion to the upper and lower extremity on one side.
Per the Quarterly assessment dated [DATE], the BIMS score for Resident #107 was again 15. The resident
was noted with limited range of motion to the upper and lower extremity on one side.
Per the last Quarterly assessment dated [DATE], the BIMS score for Resident #107 was incomplete and
not based on an interview with the resident. He was noted with limited range of motion to the upper and
lower extremity on one side.
The most recent Care Plan with a review date of 3/24/2022, failed to address the left hand contracture.
There were no focus areas, goals or interventions listed.
A review of a quarterly Rehab Referral/Screening performed on 3/31/2022, revealed the resident was
screened by a therapist. There were no recommendations during this review.
A review of a quarterly Rehab Referral/Screening performed on 12/20/2021, revealed the resident was
screened by a therapist. The recommendations during the screening were documented as: Mobility
including transfers and ambulation; recent change - patiently currently on hospice services; resident is
appropriate for physical therapy evaluation, sliding board transfers. There were no additional
screenings/recommendations found to address the resident's request for a splint or splinting needs related
to the resident's left hand contracture.
During an interview on 5/18/2022 at 1:50 p.m. with the Rehab Director, she stated all residents in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105589
If continuation sheet
Page 3 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105589
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coquina Center
170 N Center Street
Ormond Beach, FL 32174
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the facility were screened by rehab quarterly. Resident #107 had been on caseload twice per his request.
Once for a scooter assessment and then for physical therapy to work on transfers. She stated during the
survey she had gone to see the resident regarding his desire for a splint and concluded that he could
definitely benefit from having one. When asked why the resident was never assessed for a splint prior to the
survey she stated: I'm not sure how it was missed. I can't explain. I will do the evaluation and reach out to
Hospice.
During an interview on 518/2022 at 1:55 p.m. with the Director of Nursing (DON), she advised that all
residents were assessed by nursing upon admission. She stated if a resident had a contracture, it would be
the responsibility of the nursing department to refer the resident to therapy for an evaluation.
During an interview on 5/18/2022 at 4:45 p.m. MDS Coordinator A, she stated the initial assessments were
done upon admission. The facility scheduled the quarterly and annual assessments monthly. She stated the
care plan review was opened and setup at the same time an assessment was scheduled. No one audited
or reviewed the assessments for accuracy. The person completing the section is signing off that it's
accurate. She stated the nursing assessment flowed into the MDS. When asked, MDS Coordinator A stated
she was familiar with Resident #107. A record review was conducted with her. Upon review of the MDS
assessments dated 9/21/2021, 12/22/2021 and 3/24/2022, she acknowledged that the BIMS score was not
assessed appropriately on the 3/24/2022 MDS. She stated if a resident was accurately assessed for
contractures/limited range of motion in the MDS, that concern would have been added to the resident's
care plan.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105589
If continuation sheet
Page 4 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105589
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coquina Center
170 N Center Street
Ormond Beach, FL 32174
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
Based on record reviews and interviews, the facility failed to 1) Maintain a hospice plan of care and
documentation of care in the resident record, 2) Designate a member of the facility's interdisciplinary team
to coordinate care, and 3) Coordinate Hospice care for one (Resident #111) of five residents reviewed for
hospice services/coordination of care, from a total sample of 39 residents.
The findings include:
A review of Resident #111's medical record revealed an admission date of 5/28/19 with diagnoses including
non-infective gastroenteritis and colitis, dysphagia, hemiplegia and hemiparesis on left side, dementia,
delusional disorders, major depressive disorder with mixed anxiety, and depressed mood. The resident had
an active Do Not Rescusitate order.
A review of the Quarterly MDS assessment, dated 3/24/22, revealed she was receiving Hospice services.
A review of Resident #111's physician's orders revealed a Do Not Resuscitate order dated 1/28/22.
On 1/22/22, a Hospice consult was ordered.
On 2/1/22, Hospice Medicaid began.
A 5/17/22 review of the active Care Plan, revealed a focus area for End Stage of Life (initiated on 10/1/20).
The resident was not documented as receiving Hospice services; palliative care was in place. No update
had been made to the care plan at the initiation of Hospice services on 2/1/22.
A review of the Quarterly MDS assessment, dated 3/24/22, revealed the resident was receiving Hospice
services.
On 5/18/22 at 11:00 AM, five Hospice charts were reviewed. Four of the five charts had documentation
from the Hospice provider with fax dates of 5/17/22. Resident #111 did not have any documents from the
Hospice provider in her chart on this date.
On 5/18/22 at 11:20 AM, assistance was requested with obtaining Hospice notes for Resident #111. The
Administrator stated the Hospice provider had not been sending their notes to the facility. She stated she
would reach out to the provider to have the notes sent to the facility. When asked if that meant staff had no
opportunity for coordination of care, she replied yes.
On 5/18/22 at 11:30 AM, an interview was conducted with Health Information Coordinator (HIC) C. She was
asked who followed up with the Hospice provider to ensure records were being sent to the facility. She
stated, No one really, but we will now do follow up to make sure the facility receives the notes.
On 5/18/22 at 1:20 PM, an interview was conducted with the IDON. She stated the facility became aware of
the documentation issue with the Hospice provider after having been prompted by the survey team. She
further stated the facility initiated a facility assessment to identify issues to be addressed. When aked who
the Hospice coordinator was, the IDON stated she thought it was the Social Worker.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105589
If continuation sheet
Page 5 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105589
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coquina Center
170 N Center Street
Ormond Beach, FL 32174
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Then she stated she was mistaken, it was MDS Coordinator A.
Level of Harm - Minimal harm
or potential for actual harm
On 5/18/22 at 4:45 PM, an interview was conducted with RN/MDS Coordinator A. When asked if she was
the designated Hospice coordinator, she stated, I guess I have a new title. When asked how the Hospice
care plans were incorporated into the facility care plans, she stated the Hospice provider sent the care
plans to the facility and they were given to the MDS coordinator to incorporate into the care plan. Then they
were given to the HIC who either scanned them into the electronic medical record or put the hard copies in
the residents' charts.
Residents Affected - Few
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105589
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
Provide 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.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
FAQ · About this visit
Common questions about this visit
What happened during the May 19, 2022 survey of COQUINA CENTER?
This was a inspection survey of COQUINA CENTER on May 19, 2022. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COQUINA CENTER on May 19, 2022?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.