Cycle 1
Health 2025-01-24 · Fire 2025-01-24
10 health deficiencies
Top issue: Administration (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Oviedo, FL
Legacy Pointe At Ucf
1-star overall rating with 2-star inspections with abuse icon flag with 10 recent health deficiencies
2120 Hestia Loop, Oviedo, FL
(407) 543-6350
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2023-12-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,923
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0004
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.53
Performance 20.72% · Measure score 1.53 · Achievement 1.53 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.25
Performance 6.86% · Measure score 3.25 · Achievement 3.25 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
9.29
Performance 5.72 hours · Measure score 9.29 · Achievement 9.29 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.23% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 141 · Observed rate 13.48% · Lower 95% interval 8.09% |
| Discharge to community | 64.87% |
50.57%
14.3 pts better
|
Better than the National Rate · Eligible stays 131 · Observed rate 62.6% · Lower 95% interval 59.11% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.31% |
95.27%
3 pts better
|
Numerator 291 · Denominator 296 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 296 |
| Discharge self-care score | 62.04% |
53.69%
8.4 pts better
|
Numerator 134 · Denominator 216 |
| Discharge mobility score | 58.8% |
50.94%
7.9 pts better
|
Numerator 127 · Denominator 216 |
| Pressure ulcers or injuries, new or worsened | 6.1% |
2.29%
3.8 pts worse
|
Numerator 18 · Denominator 295 · Adjusted rate 6.75% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 179 · Observed rate 6.15% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 2.94% |
8.2%
5.3 pts worse
|
Numerator 2 · Denominator 68 |
| Staff flu vaccination coverage | 11.57% |
42%
30.4 pts worse
|
Numerator 14 · Denominator 121 |
| Discharge function score | 72.69% |
56.45%
16.2 pts better
|
Numerator 157 · Denominator 216 |
| Transfer of health information to provider | 98.65% |
95.95%
2.7 pts better
|
Numerator 73 · Denominator 74 |
| Transfer of health information to patient | 97.47% |
96.28%
1.2 pts better
|
Numerator 193 · Denominator 198 |
| Resident COVID-19 vaccinations up to date | 15.17% |
25.2%
10 pts worse
|
Numerator 22 · Denominator 145 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.9 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.2
0.9 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
97.8%
2.3 pts worse
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.5% |
2.6%
4.9 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.9%
1.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
15.7%
2.4 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
9.8%
1.1 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.0% |
9.8%
17.2 pts worse
|
14.9%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
0.8%
0.8 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
12.5%
9.2 pts worse
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.1%
3.1 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
94.3%
3.2 pts worse
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 88.8% · Q3 93.6% · Q4 90.5% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
9.3%
1 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 7.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.8% · Q3 0.9% · Q4 0.9% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
94.7%
7.6 pts worse
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
26.2%
1.3 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 26.0% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-16
J · Immediate jeopardy
2025-11-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-16
F · Potential for more than minimal harm
2025-01-24
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-24
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-24
E · Potential for more than minimal harm
2023-11-16
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-16
C · Minimal harm
2023-11-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-16
Penalties and ownership
What sits behind the stars
Ownership
Ccrc Development Corporation
5% Or Greater Direct Ownership Interest · Organization
Anderson, Phillip
Corporate Officer · Individual
Bangs, Terry
Corporate Director · Individual
Bloom, Warren
Corporate Director · Individual
Bowers, Russell
Corporate Director · Individual
Frame, Adrienne
Corporate Director · Individual
Francis, Albert
Corporate Officer · Individual
Gmsc Florida LLC
Operational/Managerial Control · Organization
Goff, Barry
Corporate Director · Individual
Hagerty, Kathleen
Corporate Director · Individual
Lightman, Anthony
Corporate Director · Individual
Pabst-Steinmetz, Margery
Corporate Director · Individual
Rigel, Robert
Corporate Director · Individual
Smaage, Kevin
W-2 Managing Employee · Individual
Sole, Mary
Corporate Director · Individual
U.s. Bank
5% Or Greater Mortgage Interest · Organization
Wang, Youcheng
Corporate Director · Individual
Wehmann, Domenica
W-2 Managing Employee · Individual
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