Legacy Pointe at Ucf

In the surveyor’s words

From the most serious findings on record at Legacy Pointe at Ucf, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 19, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Nov 19, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF847Jan 24, 2025

  Based 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. Findings: Review of the facility's Nursing Admission and Care Agreement revealed an Arbitration Provision in Section I of the agreement. The document contained language stating that agreeing to resolve disputes as set forth herein was not a precondition for receiving medical treatment or for admission. The document language further revealed, (the resident) did also acknowledge that he or she has had the right and opportunity to consult with an attorney prior to signing the Admission and Care Agreement and to seek any explanation or clarification desired. […]

• No harm, potential for more than minimal, widespreadF848Jan 24, 2025

  Based 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. Findings: Review of the facility's Nursing Admission and Care Agreement revealed an Arbitration Provision in Section I of the agreement. The document contained language stating the arbitration would be referred to, conducted by and resolved in accordance with the American Arbitration Association's rules and parameters at a formal arbitration hearing. […]

• No harm, potential for more than minimal, patternF623Jan 24, 2025

  Based 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 hospitalization s, of a total sample of 26 residents, (#10, #25, #31 and #38). Findings: 1. Review of resident #25's medical record revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her diagnoses included myocardial infarction, type 2 diabetes, congestive heart failure, and fracture of right ileum. Review of the Minimum Data Set (MDS) discharge assessment with Assessment Reference Date (ARD) of 8/12/24 revealed resident #25 had an unplanned transfer to a short-term acute care hospital. […]