Coquina Center

    170 N Center St, Ormond Beach, FL, 32174
    • Assisted living
    • Memory care
    • Skilled nursing
    AnonymousLoved one of resident
    2.0

    Kind staff, chronic understaffing, neglect

    I had a mixed, ultimately heartbreaking experience. Many CNAs, nurses and rehab staff were kind, professional and genuinely helpful, and parts of the facility and grounds looked clean and welcoming. But chronic understaffing, high turnover and poor administration meant slow or unresponsive care (long call-light waits, delayed meds, missed bathing/toileting), misplaced belongings, pests/mold in some rooms, wounds/bedsores and hospitalizations - with poor communication to family. Because of the neglect and unreliable management, I cannot recommend it for long-term care despite some excellent people there.

    Pricing

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    3.72 · 204 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.0
    • Staff

      3.4
    • Meals

      2.3
    • Amenities

      2.9
    • Value

      1.3

    Pros

    • Compassionate, knowledgeable physical and occupational therapy/rehab staff
    • Therapy often described as excellent and effective
    • Many reviewers praise individual CNAs and nurses as kind and attentive
    • Active, engaging activities program with multiple activity rooms
    • Beautiful grounds, trees, walkways and well-kept landscaping
    • Clean, well-maintained common areas reported by many
    • Private rooms with private baths available
    • Mobility equipment provided when available
    • Weekend buffet breakfast and cooked-to-order breakfast bar
    • Meal choices and the ability for families to bring special dishes/snacks
    • Welcoming admissions and social services staff (named staff praised)
    • Open/ flexible visitation policy in many reports
    • Sitting rooms, patio areas and pleasant communal spaces
    • Computer check-in and some visible safety/sanitizing measures
    • In-room dining service available
    • Day-shift staff frequently described as responsive and caring
    • Families able to observe treatments and participate in care planning
    • Some reviewers report spotless, odor-free hallways and rooms
    • Helpful, knowledgeable front-desk and administrative admissions team in many accounts
    • Warm, family-like atmosphere reported by multiple families
    • Staff that 'go above and beyond' and show advocacy for residents
    • Ability to regain strength and progress during short rehab stays
    • Positive reports of cleanliness and organization in many stays
    • Professional and courteous therapy and support staff
    • Multiple reports of a comforting, peaceful environment and sense of safety

    Cons

    • Filthy rooms and bathrooms reported repeatedly
    • Cockroaches, flies, bugs and reports of mold/black mold
    • Inconsistent cleanliness across rooms and shifts
    • Slow or no response to call lights, especially nights/afternoons
    • Chronic understaffing and reliance on agency/temporary staff
    • High staff turnover and lack of core long-term staff
    • Inconsistent nursing quality between day and night shifts
    • Missed, delayed, or inconsistently administered medications
    • Neglect resulting in bedsores, infections, severe hygiene lapses
    • Wet briefs/diapers left for hours and inadequate bathing/personal care
    • Allegations of theft or missing personal belongings
    • Delayed ambulance/hospital transfers and long ER waits
    • Poor communication from administration, case managers, and nursing
    • Billing/insurance confusion and issues with discharge planning
    • Premature discharges and lack of post-discharge follow-through
    • Inadequate equipment provided for some patients (wheelchairs, oxygen, trach supplies)
    • Meals late, skipped, monotonous, or diabetic-unfriendly; poor food quality reported
    • Staff rudeness, poor bedside manner, gaslighting and hostile interactions
    • Reports of falsified grievances, altered orders, and hostile management
    • Door access/locked doors after hours creating inconvenience or safety concerns
    • Dirty linens, ripped bedding, overflowing trash and housekeeping lapses
    • Untrained overnight aides and lack of supervision on night shifts
    • Safety incidents (falls, delayed X-rays, missed vitals) and inadequate monitoring
    • Reports of overmedicating to avoid manual care tasks
    • Failure to notify families about critical changes, wounds, or infections
    • Allegations of profiteering/corporate cost-cutting at expense of care
    • Poorly coordinated therapy or sudden therapy stops without family notice
    • Inconsistent COVID/infection reporting and sanitation practices
    • Long wait times for basic assistance (food, water, toileting)

    Summary review

    Overall sentiment in the reviews for Coquina Center is highly mixed and polarized. Many reviewers strongly praise certain departments and individual staff members—particularly physical and occupational therapy teams, some CNAs, and admissions/social services staff—while an equally large set of reviews describe serious problems with nursing care, cleanliness, management, and safety. The pattern across reviews suggests two distinct experiences: short-term rehab stays where therapy and rehab services are frequently excellent, and longer-term or overnight care experiences where staffing, hygiene, and oversight problems are more likely to emerge.

    Care quality and clinical safety show a clear split by service type and shift. The rehabilitation teams receive consistent, glowing remarks: reviewers call the PT/OT 'wonderful,' 'the best in the state,' and credit therapists with helping residents regain strength. These therapy staff are described as knowledgeable, professional, and compassionate, and families often appreciate being able to observe treatments and engage in care planning. In contrast, basic nursing and long-term custodial care receive numerous critical reports: delayed or missed medications, poor communication about changes in condition, missed dialysis or other important services, inadequate monitoring of wounds leading to bedsores or infections, and alarming accounts of neglect (wet briefs left for hours, patients left unattended in pain, or unattended toileting needs). Several reviewers report hospital transfers, ICU stays, sepsis, or other serious medical events that they attribute to lapses at the facility.

    Staffing and workforce issues are a dominant theme. Many positive reviews single out compassionate individual CNAs and nurses, yet many other reviews emphasize chronic understaffing, heavy reliance on agency staff, high turnover, and a notable decline in experienced core staff over time. Multiple reviewers highlight a shift-quality problem: day shifts and therapy staff tend to be responsive and professional, while afternoon and night shifts are frequently described as slow, untrained, or inattentive. This variability contributes to inconsistent resident experiences and directly links to many safety and hygiene complaints. Several reviews allege hostile management practices, falsified grievances, or a workplace culture that discourages whistleblowing—serious governance concerns that, if accurate, would worsen retention and accountability.

    Facility cleanliness and environment are reported inconsistently. Positive accounts note clean, well-maintained common areas, spotless hallways, attractive landscaping and walkways, and pleasant communal spaces (sitting rooms, patios). Conversely, a large number of reviews report unacceptable room conditions: dirty bathrooms, sticky floors, overflowing trash, insects (cockroaches, flies), and even mold in some cases. Laundry and linen problems—ripped or soiled sheets, missing clothing—are reported as well. These contradictions suggest that housekeeping standards vary by unit, room, or time, and that quality control is inconsistent.

    Dining and daily living services receive mixed feedback. Some reviewers like the variety, weekend breakfast buffet, and cooked-to-order breakfast bar and appreciate the option to bring special dishes. Others describe the food as monotonous, cold, late, or unsuitable for special diets (diabetic-unfriendly or soft-diet problems). Reports of meals being skipped, delayed trays, or evening dining limitations (kitchen closure) indicate operational lapses that affect resident satisfaction. Additionally, practical issues such as locked doors after 6pm, difficulty getting water or mobility aids for transport, and inaccessible call bells exacerbate everyday safety and dignity concerns for some residents.

    Management, communication, and discharge/administrative processes are recurring points of concern. While several reviewers praise specific admissions or social services staff by name and find administration responsive, a substantial number report poor communication from management, difficulty reaching nurses or case managers, and lack of follow-through on care plans or medication orders. Discharge coordination and billing/insurance handling are cited as problematic in multiple instances—insurance lapses, therapy stopped because of funding issues, or medication not called into pharmacy at discharge. Some reviews allege that corporate cost-cutting harms resident care; others describe administrators who did not promptly return calls or who were unhelpful during emergencies.

    Given these patterns, families should approach Coquina Center with both appreciation for its clear strengths and caution about its serious and recurring weaknesses. The facility may be a strong option for short-term rehabilitation where PT/OT is the primary need, as therapy teams are frequently singled out for excellence. For long-term stays or for residents who require continuous nursing supervision (night care, complex medical devices, strict medication schedules, diabetes management), the reviews raise enough consistent red flags—staffing inconsistency, delayed medications, hygiene lapses, infection and wound concerns, infrequent call responsiveness—that families should conduct careful due diligence.

    Practical recommendations for prospective residents and families: tour the specific unit and inspect resident rooms and bathrooms for cleanliness; ask directly about night staffing levels and agency staff reliance; request documentation on infection control, pest control, and mold remediation; clarify medication administration protocols, emergency transfer procedures, and how the facility handles diabetic or special diets; get written commitments about therapy frequency and discharge planning; and obtain contact information for an on-site manager and a chain-of-command for unresolved concerns. Also consider seeking references from recent short-stay rehab families if therapy is the primary need, and talk to long-term residents’ families about consistency across shifts if continuous nursing care will be required.

    In summary, Coquina Center elicits strongly divergent experiences. Its rehab and therapy services and many individual staff members are repeatedly praised, and the campus and communal areas are often described as attractive and well cared for. However, numerous, serious complaints about nursing care, hygiene, staffing, and management create a pattern of risk for residents needing high-reliability nursing and safety oversight. Those considering Coquina should weigh the facility’s therapy strengths against documented lapses in long-term nursing and housekeeping, and take concrete steps to verify current conditions and staffing before committing to a placement.

    Location

    Map showing location of Coquina Center

    About Coquina Center

    Opis Coquina Center is a nursing home in Florida with 120 certified beds, though it usually has about 108 residents each day, and it runs under Opis Senior Services Group. The center has private and semi-private rooms with cable TV, telephones, and internet access in each, plus an Internet café, shared common areas, and outdoor spaces where residents can spend time with others or just sit quietly, and there's always air conditioning. The building is wheelchair accessible, has restrooms throughout, parking, and a beauty salon and barbershop on site, so people can get what they need without leaving the property. Residents get three meals a day from a dining service that focuses on nutrition, and there are activities like games, hobbies, and social events, with a few special programs that go by unique names.

    Care services cover a lot of ground, from short-term rehab and post-surgical care to long-term, respite, and palliative care, and staff offer therapies such as occupational, physical, and speech therapy. There's also a secured memory care unit for people with Alzheimer's and dementia, and the center offers help with daily living tasks such as bathing, dressing, and managing medicine. There's wound care, cognitive and adaptive therapies, housekeeping, and laundry service included, and the facility's rated 4.2 out of 5 across 50 reviews, showing a mix of experiences.

    Opis Coquina Center is for-profit and managed by Gabriel Living Center, LLC since April 2003. Nurses provide about 3.25 hours of care per resident daily, which is below the state average of 3.9, and the nurse turnover rate sits at 75.2%, higher than the state's 43.6%. The center's had inspection reports with at least 7 total deficiencies, including issues with care plans and resident treatment, but none have resulted in actual harm, only the potential for more than minimal harm. It's been accredited by the Joint Commission and has received community awards such as Best of Senior Living and All-Star, and people often notice the staff's friendly, helpful, and kind attitude.

    Families will find options for family caregiving resources and guidance, and the facility is set up to feel home-inspired, with modern touches and a focus on happiness and comfort. Residents can join in social, mental, and physical wellness activities, with the staff aiming to create better quality of life and support for everyone living there, all while offering medical, nursing, and home healthcare services for a range of needs.

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