Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy Pointe At Ucf during CMS and state inspections, most recent first.
Failure to Individualize UTI Care Plan: A cognitively intact resident with a UTI had lower abdominal pain and dysuria, with urine culture results showing E. coli and an order for Macrobid. The baseline care plan only noted an infection and listed contact isolation, droplet isolation, and standard precautions without identifying the specific infection or which precautions were appropriate; the RN MDS Interim Coordinator confirmed the care plan was not resident-specific or individualized.
Failure to Follow EBP During Wound Care: A resident with multiple wounds, active wound care orders, and treatment for a wound infection was observed during wound care while an RN performed hand hygiene but did not don a gown despite an EBP sign requiring gown and gloves for high-contact care. The RN touched the resident's leg and foot and contacted environmental surfaces during the procedure, while an LPN confirmed the EBP requirement and acknowledged that staff providing high-contact care should wear the appropriate PPE.
A resident with severe cognitive impairment and documented elopement risk exited through a stairwell emergency exit after the door failed to lock or alarm and the screamer alarm was found turned off. The resident had a walker, a wander alert bracelet order, and no baseline or comprehensive care plan addressing elopement risk before the event. Staff did not know his whereabouts until he was seen outside by maintenance, and the report states he could have fallen, gone to the roof, or been hit by a car.
A resident with severe cognitive impairment and known elopement risk exited the unit unsupervised after leaving his room and using a stairwell emergency exit door that did not alarm or lock as expected. Staff did not know his whereabouts until he was found outside on the sidewalk near a parking area and drive, after he had descended stairs with his walker and walked away from the unit. The resident’s record did not contain an elopement care plan before the event, despite his dementia, walker use, and documented risk for wandering and falls.
The facility failed to inform residents or their representatives of their right to rescind the arbitration agreement within 30 days of signing. The agreement lacked a separate section for accepting or declining the arbitration provision, and the Admission Coordinator confirmed that the agreement was required for admission. The Administrator acknowledged the need for a separate signature line and the omission of the rescindment period.
The facility's arbitration agreement failed to include provisions for selecting a neutral arbitrator and a convenient venue, as confirmed by the Admission Coordinator and Administrator. The agreement referred to the American Arbitration Association's rules but did not inform residents of their rights in the arbitration process.
The facility failed to provide written Notification of Transfer or Discharge forms to residents, their representatives, and the Ombudsman for four residents hospitalized. Despite multiple hospital transfers, the facility did not document or communicate these transfers as required. Staff interviews revealed confusion about responsibilities, and the Director of Nursing acknowledged the forms were not completed. The Administrator admitted the process fell through due to staff changes.
The facility failed to ensure nursing staff had the necessary competencies for medication administration, leading to multiple errors. A resident received incorrect antibiotics due to transcription errors, and another resident was given undiluted potassium chloride against label instructions. Additionally, a nurse left medications unattended and documented administration of unavailable medications. The facility lacked evidence of annual competencies for nursing staff.
The facility failed to maintain effective QAA policies, resulting in repeated deficiencies in nursing competency and infection control. Despite creating Performance Improvement Plans and conducting root cause analyses, the facility did not sustain corrective actions, leading to repeat citations. The NHA admitted the QAPI system was ineffective, and the DON was unaware of previous survey findings.
The facility failed to follow its grievance process for two residents, leading to unresolved concerns and inadequate documentation. A resident reported missing items and improper transfer by a CNA, while another experienced medication discrepancies and poor communication about discharge plans. Grievances were not properly logged or addressed, indicating a lapse in the facility's policy adherence.
A medication cup with seven pills was left unattended on a locked medication cart in the Blue Unit. The RN responsible was called away for an emergency and believed she had secured the medication. The ADON confirmed that while nurses received training, competencies were not completed, and the facility's policy required medications to be locked and not left unattended.
An LPN failed to follow infection control practices during medication administration by not disinfecting a mobile vital signs device and neglecting hand hygiene before and after resident contact. The resident was on enhanced barrier precautions, and the LPN reused a gown and handled medications without proper hand hygiene. The facility's policy emphasized hand hygiene, but the LPN did not adhere to these guidelines.
Failure to Individualize UTI Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for a resident with a urinary tract infection. The resident was admitted with diagnoses including lower back pain with left side sciatica, spinal stenosis, epigastric mass, heart disease, diverticulosis, and bacteria in the urine. The admission MDS showed a BIMS score of 15/15, indicating the resident was cognitively intact, and the active diagnosis included a urinary tract infection in the past 30 days. An advanced practice nurse progress note documented complaints of lower abdominal pain and pain during urination, and a urine culture was ordered. Laboratory results showed Escherichia coli in the urine, and a physician order was entered for Macrobid 100 mg twice daily for seven days for UTI. The resident’s baseline care plan identified an infection, but it was not individualized to specify the type of infection. The listed interventions included contact isolation, droplet isolation, and standard precautions, but did not identify which precautions were appropriate for the resident’s infection. The RN MDS Interim Coordinator reviewed the care plan and verified that it did not identify the infection or specify any appropriate precautions, and acknowledged that it should have been updated to include the type of infection, necessary precautions, and antibiotic therapy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices related to Enhanced Barrier Precautions for one resident who had multiple wounds and active wound care orders. The resident was admitted with diagnoses including Parkinson's disease, chronic kidney disease, a history of non-ST elevation myocardial infarction, atrial fibrillation, heart failure, hypertension, glaucoma, cognitive communication deficit, and a history of non-Hodgkin lymphoma in remission. Current physician orders showed wound care for coccyx, left heel, and spine wounds, along with offloading interventions and topical treatments. The resident also had active Enhanced Barrier Precautions related to a wound infection and was receiving IV Meropenem and oral Linezolid for the infection, with a midline IV ordered for flushing, dressing changes, and monitoring for signs and symptoms of infection. During observed wound care, hand hygiene was performed before the procedure began, but the RN did not don a gown before starting the high-contact care. The RN leaned on the resident's bed, touched the resident's leg and foot, and came into contact with multiple environmental surfaces without wearing a gown. The RN held the resident's leg and foot while the cart nurse cleansed the wound. The resident's door had an EBP sign indicating that a gown and gloves were required during high-contact care, and the LPN later confirmed the sign and stated awareness that staff providing high-contact care should wear the appropriate protective equipment, including a gown and gloves. The facility's policy stated that staff were required to wear gown and gloves during high-contact resident care activities, including wound care, to prevent transmission of multidrug-resistant organisms.
Unsecured Exit Allowed Unsanctioned Resident Elopement
Penalty
Summary
The facility failed to protect a resident from neglect by not maintaining a secure environment and not implementing measures to reduce elopement risk for a resident with severe cognitive impairment. The resident was an older male admitted with diagnoses including unspecified dementia, metabolic encephalopathy, unsteadiness on feet, muscle weakness, and other gait and mobility abnormalities. His MDS admission assessment showed a BIMS score of 3/15, indicating severe cognitive impairment, and the record showed he used a wander/elopement alarm daily and ambulated with a walker. The resident had an order for an electronic wander alert bracelet, and an elopement risk assessment identified him as at risk for elopement. However, the record showed no baseline or comprehensive care plan had been developed or initiated to address his elopement risk before the event. On the day of the incident, the resident exited the facility unsupervised and the facility was unaware of his whereabouts until he was observed outside on the sidewalk by maintenance staff. He was later returned to the unit. The report states that while he was outside the unit unsupervised, there was reasonable likelihood he could have gone up to the roof and fallen off, fallen down the stairs with his walker, or been hit by a car. Survey findings showed the resident exited through the second floor stairwell emergency exit door on the nursing unit. The door was found to have a wander alert sensor, a red screamer alarm, and a 15-second egress feature, but the facility determined the door malfunctioned and did not lock or alarm when the resident exited. The Administrator also stated the red screamer alarm had been turned to the off position, and the facility could not determine which employee did so. The report further noted there were contractors working in the unit that day and that the work may have affected the door function.
Unsupervised Elopement Through Stairwell Exit
Penalty
Summary
The facility failed to provide adequate supervision to maintain a secure environment for a resident with severe cognitive impairment who was at risk for elopement. The resident had diagnoses including unspecified dementia, metabolic encephalopathy, unsteadiness on feet, muscle weakness, and other gait and mobility abnormalities. His admission MDS showed a BIMS score of 3/15, indicating severe cognitive impairment, and the record showed he used a wander/elopement alarm daily and was assessed as being at risk for elopement and high risk for falls. On the day of the event, the resident was last documented in his room by a CNA at about 2:00 PM. Staff interviews and statements indicated he was later seen outside the facility unsupervised, and the facility was not aware of his whereabouts until a maintenance staff member observed him on the sidewalk and stopped to check on him. The resident had exited through the second-floor stairwell emergency exit door, descended the stairwell with his walker, and then walked outside along the sidewalk near a parking area and drive before being found. The resident told staff he was trying to get across the road into the woods where he left his car. The record review showed the comprehensive care plan did not contain an elopement or wander-risk care plan prior to the event, despite the resident’s known cognitive impairment and elopement risk. Interviews with staff and leadership indicated the stairwell emergency exit door did not alarm or lock as expected at the time of the event, and the resident was able to leave the unit without staff knowledge. The report also states there was a reasonable likelihood he could have gone to the roof and fallen off, fallen down the stairs with his walker, or been hit by a car.
Failure to Inform Residents of Right to Rescind Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it. The Nursing Admission and Care Agreement included an Arbitration Provision, which was not a precondition for receiving medical treatment or admission. However, the agreement did not have a separate section or signature line for the resident or representative to accept or decline the Arbitration Provision separately from the entire admission and care agreement. Additionally, the agreement lacked a statement informing the resident or representative of their right to rescind the agreement within 30 days. The Skilled Nursing Facility Admission Coordinator confirmed that the admission agreement was required to be signed for admission and acknowledged that there was no specific signature line for declining the arbitration provision. She stated that residents or representatives could write 'declined' or draw a line through the provision and initial the page if they wished to decline. The Administrator reviewed the arbitration provision and acknowledged that it appeared to be part of the required admission agreement and should have a separate signature line. He also confirmed that the wording did not explicitly grant the resident or representative 30 days to rescind the agreement.
Deficiency in Arbitration Agreement Provisions
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement included provisions for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue convenient to both parties. The Nursing Admission and Care Agreement contained an Arbitration Provision that referred to the American Arbitration Association's rules but did not explicitly state the rights of residents or their representatives to choose a neutral arbitrator or a convenient venue. This omission was identified during a review of the agreement. Interviews with the Skilled Nursing Facility Admission Coordinator and the Administrator confirmed the deficiency. The Admission Coordinator, responsible for obtaining signatures on the admission agreement, acknowledged the lack of information regarding the selection of a neutral arbitrator and a convenient venue. She also admitted to being unaware of the specific rules of the American Arbitration Association. The Administrator verified the absence of necessary language in the arbitration provision and recognized the need for residents to be informed of their rights in the arbitration process.
Failure to Provide Notification of Transfer or Discharge Forms
Penalty
Summary
The facility failed to provide written Notification of Transfer or Discharge forms to residents, their representatives, and the Ombudsman for four residents who were hospitalized. This deficiency was identified through interviews and record reviews, which revealed that the medical records of these residents did not contain the required notification forms for their hospitalizations. The residents involved had various medical conditions, including myocardial infarction, type 2 diabetes, congestive heart failure, cerebral atherosclerosis, Parkinson's disease, and vascular dementia. Despite multiple hospital transfers, the facility did not document or communicate these transfers as required. Interviews with facility staff, including the Assistant Director of Nursing, Social Services Director, Director of Nursing, and the Administrator, confirmed the lack of proper documentation and communication. The staff were unclear about their responsibilities regarding the completion and distribution of the Notification of Transfer or Discharge forms. The Director of Nursing acknowledged that the forms were not being completed, and the Administrator admitted that the process had fallen through due to staff changes. The facility's policy required written notification to the State Long-Term Care Ombudsman for hospital transfers, which was not adhered to in these cases.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets required for medication administration and storage, as evidenced by multiple incidents involving medication errors and improper handling of medications. One resident, who was admitted for IV antibiotics, experienced a series of medication errors due to incorrect transcription of antibiotic orders. The resident's wife reported that the facility was ill-prepared for his admission, and the antibiotics were not available upon his arrival. The orders were entered incorrectly, leading to the administration of the wrong antibiotic on two occasions. The Director of Nursing (DON) and other staff were unaware of the error until days later, and the resident's primary care physician was not informed of the mistake. Another incident involved a nurse administering potassium chloride (KCl) to a resident without diluting it as per the medication's instructions. The nurse stated that the resident preferred to take the KCl undiluted, but there was no documentation of physician approval for this method of administration. This action contradicted the medication's label instructions and could cause gastrointestinal irritation. Additionally, a nurse left a cup of medications unattended on a medication cart, which was a breach of protocol. The nurse later admitted to documenting that all medications were administered when, in fact, some were not available at the time. The facility lacked evidence of annual competencies for medication administration for the nursing staff, and the DON acknowledged that such competencies were crucial for ensuring the safe administration of medications to residents.
Repeat Deficiencies in Nursing Competency and Infection Control
Penalty
Summary
The facility failed to implement its Quality Assessment and Assurance (QAA) policies effectively, leading to repeated deficiencies in competent nursing staff and infection prevention and control. The QAA policy, which was not dated, outlined that the Nursing Home Administrator (NHA), Director of Nursing (DON), and Medical Director were responsible for monitoring quality of care and life for residents. The policy required the QAA committee to meet at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. However, the facility did not adequately track performance or ensure competent nursing staff and infection prevention measures were in place, as evidenced by repeat citations of F726 and F880 during the certification survey. During an interview, the NHA explained that departments conducted audits to identify trends or concerns, which were then addressed in QAPI meetings. Despite creating Performance Improvement Plans (PIP) and conducting root cause analyses, the facility failed to maintain corrective actions from the last survey. The NHA admitted that the QAPI system was ineffective, and the DON was unaware of previous survey findings. The facility's inability to sustain monitoring and oversight led to the recurrence of deficiencies, indicating a lack of continuity in implementing corrective measures.
Failure to Follow Grievance Process for Residents
Penalty
Summary
The facility failed to adhere to its grievance process for two residents, resulting in unaddressed concerns and grievances not being properly logged or resolved. Resident #21, who was cognitively intact, reported missing personal items and an incident where a CNA improperly transferred her, causing a healed wound to reopen. Despite completing grievance forms regarding these issues, the grievances were not logged in the facility's Grievance Log, and the Social Services Director did not obtain a copy of the grievance form related to medication costs, assuming the issue was resolved without needing the form. Resident #443, also cognitively intact, experienced issues with his admission process, including medication discrepancies and inadequate care for his hearing aids. His wife expressed concerns about the facility's preparedness and the lack of communication regarding his discharge plans. Although a grievance was filed by his wife regarding the discharge request, another grievance related to the same issue was not logged separately, as the Social Services Director attached it to the existing grievance. The Nursing Home Administrator did not file a grievance form for the medication issue, attributing the problem to the sending facility. The facility's policy requires a designated grievance official to track and investigate grievances, ensuring timely resolution and maintaining evidence of grievances for at least three years. However, the facility's failure to log and address grievances for both residents indicates a lapse in following this policy, leading to unresolved concerns and inadequate documentation of the grievance process.
Unattended Medication Cup on Locked Cart
Penalty
Summary
The facility failed to ensure medications were inaccessible to non-authorized staff and residents, as observed during a tour of the Blue Unit. A medication cup containing seven pills was found unattended on top of a locked medication cart. The Registered Nurse (RN) responsible for the medication explained that she had left the cup unattended due to being called away for an emergency. She believed she had placed the cup in the cart's drawer before leaving but acknowledged that leaving medications unsecured was unsafe. The Assistant Director of Nursing (ADON) confirmed that nurses received training during orientation, but competencies were not completed. The ADON stated that the protocol required nurses to discard medications safely if called away during preparation, as medications should not be left unattended. The facility's policy on medication storage emphasized that compartments containing medications must be locked when not in use, and carts should not be left unattended.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration on the Orange Wing. During an observation, an LPN retrieved a mobile vital signs device from the hallway and used it in a resident's room without disinfecting it, despite the resident being on enhanced barrier precautions. The LPN donned a gown and gloves but did not perform hand hygiene before or after entering the room. After obtaining the resident's vital signs, the LPN exited the room, removed the gown and gloves, and proceeded to handle medications without performing hand hygiene. The LPN then reused the gown, donned gloves without hand hygiene, and administered the medications. The LPN explained that she was running late and assumed the device had been disinfected by the previous user. She acknowledged the need to clean the device and perform hand hygiene but did not do so. The Infection Preventionist (IP) noted that while orientation included training, there were no records of competency forms completed. The facility's policy emphasized the importance of hand hygiene as a cornerstone of infection prevention, yet the LPN did not adhere to these guidelines. The report highlights a lack of adherence to infection control protocols, particularly in hand hygiene and equipment disinfection, during medication administration.
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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 Oviedo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tuskawilla Nursing And Rehab Center | 3.5 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Orlando | 3.8 mi | ★★★★★ | 2 | 0 |
| Regents Park Of Winter Park | 6.7 mi | ★★★★★ | 8 | 0 |
| Winter Park Care And Rehabilitation | 6.8 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Orlando | 7.1 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.