Inspection Reports for
Legacy Pointe at Ucf
2120 HESTIA LP, OVIEDO, FL, 32765
Back to Facility ProfileCitations (last 4 years)
Citations (over 4 years)
6 citations/year
Citations are regulatory findings recorded during state inspections.
30% worse than Florida average
Florida average: 4.6 citations/yearCitations per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Census: 44
Citations: 2
Date: Nov 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to protect residents from neglect and ensure a secure environment to prevent elopement of vulnerable residents.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent elopement of resident #1 on 9/16/25, resulting in immediate jeopardy which was removed on 9/19/25 after corrective actions. The facility was unaware of the resident's whereabouts until he was found outside by maintenance staff. The emergency exit door alarm malfunctioned and was intentionally disabled by an unknown staff member.
Findings
The facility failed to prevent the elopement of a cognitively impaired resident (#1) who exited the facility unsupervised through a malfunctioning emergency exit door. This failure placed the resident at risk of serious injury or death. Immediate corrective actions were implemented, including 1:1 monitoring, door audits, staff education, and policy reviews. The facility was found to be in substantial compliance as of 10/16/25.
Citations (2)
F600: The facility failed to protect residents from neglect by not maintaining a secure environment and preventing elopement for 1 of 6 residents, resulting in immediate jeopardy to resident health or safety.
F0689: The facility failed to provide adequate supervision and maintain a secure environment to prevent a cognitively impaired resident from exiting the facility unsupervised, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents at risk for elopement: 5
Resident census: 44
Staff educated on abuse, neglect, and exploitation: 32
Staff educated on elopement policy: 106
Elopement drills: 43
Temperature: 88
Distance walked by resident after elopement: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Technician A | Maintenance Technician | Witnessed resident outside and called for assistance during elopement event |
| Former Director of Nursing | Director of Nursing | Notified of resident outside, initiated 1:1 monitoring and investigation |
| Maintenance Director | Maintenance Director | Reported malfunctioning emergency exit door and disabled alarm |
| Licensed Practical Nurse C | LPN | Verified presence on day of elopement and awareness of resident |
| Activities Manager | Activities Manager | Found resident outside and accompanied him back inside |
| MDS Coordinator | MDS Coordinator | Acknowledged lack of baseline care plan for elopement risk prior to event |
| Administrator | Facility Administrator | Led investigation and corrective actions following elopement |
Inspection Report
Complaint
Citations: 1
Date: Aug 21, 2025
Visit Reason
Two class 2 deficiencies for resident care supervision.
Findings
Two class 2 deficiencies for resident care supervision.
Citations (1)
Tag A0025 — RESIDENT CARE - SUPERVISION
Inspection Report
Complaint
Citations: 1
Date: Apr 22, 2025
Visit Reason
One class 2 deficiency for resident care supervision with correction date.
Findings
One class 2 deficiency for resident care supervision with correction date.
Citations (1)
Tag A0025 — RESIDENT CARE - SUPERVISION
Inspection Report
Complaint Investigation
Citations: 8
Date: Jan 24, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to follow grievance processes, failure to provide timely notification of transfers or discharges, medication administration errors, and infection control issues.
Complaint Details
The complaint investigation substantiated multiple issues including failure to follow grievance procedures, failure to provide transfer/discharge notifications, medication errors including incorrect antibiotic administration and lack of nurse competencies, unsecured medications, inadequate arbitration agreement disclosures, insufficient quality assurance monitoring, and poor infection control practices.
Findings
The facility failed to follow grievance procedures for residents, did not provide required transfer/discharge notifications for hospitalizations, had medication administration errors including incorrect antibiotic orders and lack of nurse competencies, left medications unsecured, failed to provide proper infection control practices, and had deficiencies in arbitration agreement disclosures and quality assurance monitoring.
Citations (8)
F 0585: The facility failed to follow their grievance process for 2 of 2 residents reviewed, not documenting grievances properly or addressing concerns timely.
F 0623: The facility failed to provide written Notification of Transfer or Discharge forms to residents, representatives, and Ombudsman for 4 of 4 residents reviewed for hospitalizations.
F 0726: The facility failed to ensure nursing staff had appropriate competencies for medication administration and storage, including administration of IV antibiotics by non-IV certified nurses.
F 0761: The facility failed to ensure medications were stored securely as a medication cup with pills was left unattended on a locked medication cart.
F 0847: The facility failed to ensure the binding arbitration agreement explicitly granted residents the right to rescind the agreement within 30 days of signing.
F 0848: The facility failed to ensure the arbitration agreement provided for selection of a neutral arbitrator agreed upon by both parties and a venue convenient to both parties.
F 0867: The facility failed to implement effective quality assurance processes to monitor and correct deficiencies in nursing staff competency and infection prevention.
F 0880: The facility failed to adhere to proper infection control practices including hand hygiene and disinfection of equipment during medication administration on the Orange Wing.
Report Facts
Residents reviewed for grievances: 26
Residents reviewed for hospitalizations: 26
Residents affected by grievance deficiency: 2
Residents affected by transfer/discharge notification deficiency: 4
Nurses reviewed for medication administration competency: 3
Residents affected by infection control deficiency: 1
Current residents with arbitration provision signed: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in medication error finding related to incorrect antibiotic order entry and administration |
| LPN E | Licensed Practical Nurse | Named in medication error finding related to antibiotic administration and lack of IV certification |
| RN A | Registered Nurse | Observed leaving medication unattended and not diluting potassium chloride as prescribed |
| Director of Nursing | Director of Nursing (DON) | Responsible for nursing staff competencies and medication error oversight |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Responsible for nursing competencies and infection control oversight |
| Social Services Director | Grievance Officer | Responsible for grievance process and documentation |
| Nursing Home Administrator | Administrator | Oversight of facility operations and arbitration agreement |
| Infection Preventionist | Infection Preventionist (IP) | Responsible for infection control program and staff training |
Inspection Report
Complaint
Citations: 0
Date: Dec 19, 2024
Visit Reason
No deficiencies noted.
Findings
No deficiencies noted.
Inspection Report
Routine
Citations: 5
Date: Aug 6, 2024
Visit Reason
Multiple class 3 deficiencies related to resident care, medication, staffing, and food service.
Findings
Multiple class 3 deficiencies related to resident care, medication, staffing, and food service.
Citations (5)
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Tag A0055 — MEDICATION - STORAGE AND DISPOSAL
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0092 — FOOD SERVICE - GENERAL RESPONSIBILITIES
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Inspection Report
Routine
Citations: 7
Date: Nov 16, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, treatment and care, wound care, staff competencies, nurse staffing postings, medication administration, and infection control practices.
Findings
The facility was found deficient in honoring resident self-determination, providing treatments as ordered, conducting proper wound assessments and care, ensuring nursing staff competencies, posting nurse staffing information accurately, preventing medication errors, and adhering to infection prevention and control standards during wound care.
Citations (7)
F 0561: The facility failed to honor the right of resident #101 to make a choice regarding use of a condom catheter at night, which was not applied as ordered for over two weeks despite resident preference and physician orders.
F 0684: The facility failed to provide treatments as ordered to promote wound healing for resident #101, including failure to change a hand dressing as documented.
F 0686: The facility failed to provide appropriate pressure ulcer care for resident #104, including lack of wound assessment on admission, failure to obtain necessary wound care supplies, and incomplete wound treatment.
F 0726: The facility failed to ensure nursing staff had appropriate competencies and skills to meet residents' needs, including medication errors, improper wound care, and inadequate orientation and competency documentation for staff.
F 0732: The facility failed to post required nurse staffing information daily, omitting resident census and actual hours worked by nursing staff categories.
F 0759: The facility failed to prevent medication errors for residents #101 and #102, including omission of ordered medication and crushing medications that should be swallowed whole.
F 0880: The facility failed to implement an infection prevention and control program consistent with accepted standards, including improper hand hygiene and clean dressing change technique during wound care for resident #104.
Report Facts
Medication error rate: 9
Resident sample size: 13
Medication administration opportunities: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in medication error findings, wound care documentation issues, and orientation deficiencies |
| LPN C | Licensed Practical Nurse | Named in wound care infection control deficiencies and documentation issues |
| Director of Nursing | Director of Nursing (DON) | Provided statements on expectations for nursing care, staff competencies, and infection control |
| Certified Nursing Assistant A | Certified Nursing Assistant | Provided confirmation about condom catheter use for resident #101 |
| Licensed Practical Nurse B | Licensed Practical Nurse | Provided statements regarding condom catheter orders and wound care |
| Administrator | Facility Administrator | Provided statements regarding staffing agency use and orientation documentation |
Inspection Report
Citations: 0
Date: Jan 11, 2023
Visit Reason
No deficiencies noted.
Findings
No deficiencies noted.
Inspection Report
Citations: 0
Date: Aug 4, 2022
Visit Reason
No deficiencies noted.
Findings
No deficiencies noted.
Report
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