Legacy Square
1621 Front Street, Henderson, NE 68371 · York County · 40 certified beds · avg 35 residents/day · certified since Jun 1, 1981
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Oct 23, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 7, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (11)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 15, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 15, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 15, 2026 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Jan 15, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Oct 23, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 23, 2025 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint |
| Oct 23, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 23, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 4, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Sep 4, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 4, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 3 | 0 | E |
| 2025 | 4 | 1 | J ▲ |
| 2026 | 4 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $14,069, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Oct 23, 2025 | Fine | $14,069 |
| Oct 23, 2025 | Payment Denial | 16 days from Nov 21, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.28 | 4.33 | 3.95 | top 13% in Nebraska; top 10% in the U.S. |
| Registered Nurse hours | 1.07 | 0.72 | 0.69 | top 12% in Nebraska; top 13% in the U.S. |
| Weekend total nurse staffing | 4.60 | 3.79 | 3.50 | top 15% in Nebraska; top 11% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.47 | 0.48 | top 41% in Nebraska; top 38% in the U.S. |
| Total nursing staff turnover (%) | 23.5 | 48.7 | 45.8 | top 5% in Nebraska; top 5% in the U.S. |
| RN turnover (%) | 0.0 | 44.1 | 42.9 | top 1% in Nebraska; top 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.09, RN 0.83, weekend 3.56. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is your infection preventionist, and what training do they have?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How does your quality committee work, and can you share an example of a problem it identified and fixed?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sutton Community Home, INC. | 11.8 mi | Sutton, NE | ★★★☆☆ | 3/5 | |
| Memorial Community Care | 12.2 mi | Aurora, NE | ★★★★★ | 4/5 | |
| Westfield Quality Care of Aurora | 12.4 mi | Aurora, NE | ★☆☆☆☆ | 1/5 | |
| York General Hearthstone | 13.3 mi | York, NE | ★★★★★ | 5/5 | |
| Fairview Manor | 15.3 mi | Fairmont, NE | ★★★★★ | 5/5 | |
| Harvard Rest Haven | 18.5 mi | Harvard, NE | ★★★★☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 28E173.