Legacy Pointe at Ucf

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized person-centered care plan related to urinary tract infection (UTI) for 1 of 1 resident reviewed for care plans, of a total sample of 28 residents, (#47).

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for wound care, of a total sample of 48 residents, (#7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from neglect by not ensuring the staff maintained a secure environment and implemented measures to mitigate the risks to prevent elopement for 1 of 6 residents reviewed for elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 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. On 9/16/25 at approximately 2:00 PM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 6 residents reviewed for elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk of serious injury, impairment or death. While resident #1 was outside the unit unsupervised, there was 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. On 9/16/25 at approximately 2:00 PM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. [...]

Inspectors wroteBased on interview, and record review, 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.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the binding arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and provided for the selection of a venue that was convenient to both parties.

Inspectors wroteBased on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative and the Ombudsman for 4 of 4 residents reviewed for hospitalizations, of a total sample of 26 residents, (#10, #25, #31 and #38).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets required to meet residents' needs for medication administration and storage per nursing standards of care for 3 of 3 nurses reviewed for medication administration and storage.

Inspectors wroteBased on interview, and record review of facility documentation, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure the facility had competent nursing staff and infection prevention control measures implemented.

Inspectors wroteBased on interview, and record review, the facility failed to follow their grievance process for 2 of 2 residents reviewed for grievances, of a total sample of 26 residents, (#21 and #443).

Inspectors wroteBased on observation, and interview, the facility failed to ensure medications were inaccessible to non-authorized staff and residents in 1 of 1 medication carts on the Blue Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to hand hygiene and disinfection of equipment during medication administration on 1 of 2 units, (Orange Wing).

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets required to meet residents' needs as indicated by the plans of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the right to make a choice regarding a significant aspect of activities of daily living for 1 of 2 residents reviewed for choices, out of a total sample of 13 residents, (#101).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments as ordered to promote wound healing for 1 of 2 residents reviewed for non-pressure skin conditions, out of a total sample of 13 residents, (#101).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services according to accepted professional standards related to conducting a pressure wound assessment on admission and applying wound treatment as ordered to promote healing and prevent worsening of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers, out of a total sample of 13 residents, (#104).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent medication errors for 2 of 6 residents reviewed during the Medication Administration task, out of a total sample of 13 residents, (#101 and #102). There were 3 errors in 31 opportunities for a medication error rate of 9%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its policy and procedures for clean dressing changes reflected accepted Infection Control standards of practice; and failed to adhere to proper Infection Control practices during wound care to prevent cross-contamination for 1 of 2 residents reviewed for pressure ulcers, out of a total sample of 13 residents, (#104).

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information daily to ensure accurate and comprehensive data was accessible to residents and/or visitors.