Legacy Square

1621 Front Street · Henderson, NE · 68371 · 4027235301

40 certified beds For profit - Corporation Hospital-based

Why this verdict

  • Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
  • Inspection record is far worse than the national median (deficiency count and severity).
  • Inspection results are getting worse cycle over cycle, not better.
  • Staffing hours comfortably above national benchmarks.

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Red flags

1 immediate-jeopardy citation in the most recent inspection cycle

Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.

Medicare/Medicaid payments were denied

CMS refused payment for new admissions for a period — one of its strongest enforcement tools.

Score breakdown

Inspection record 30% of score 38
Serious harm & abuse 20% 70
Staffing 20% 84
Federal penalties 15% 56
Trend 10% 18
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 1 of 5 Staffing: 5 of 5 Quality measures: 5 of 5

Total nurse hours / resident-day4.203.48 min · 4.1 strong
RN hours / resident-day0.870.55–0.75
Weekend hours / resident-day3.55≈ weekday level
Nursing turnover / year28%median 45%
Fines (3-yr window)1 · $14,069

Inspection citations (11 in the current record)

  • Potential for harm · D January 15, 2026

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected March 1, 2026 · Resident Rights

  • Potential for harm · F January 15, 2026

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected March 1, 2026 · Nutrition and Dietary

  • Potential for harm · F January 15, 2026

    Provide and implement an infection prevention and control program.

    Corrected March 1, 2026 · Infection Control

  • Potential for harm · F January 15, 2026

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    Corrected March 1, 2026 · Infection Control

  • Immediate jeopardy · J October 23, 2025 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected December 7, 2025 · Quality of Life and Care

  • Potential for harm · D October 23, 2025 · found via complaint

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Corrected December 7, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D October 23, 2025 · found via complaint

    Respond appropriately to all alleged violations.

    Corrected December 7, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · F October 23, 2025 · found via complaint

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    Corrected December 7, 2025 · Administration

  • Potential for harm · D September 4, 2024

    Ensure medication error rates are not 5 percent or greater.

    Corrected October 19, 2024 · Pharmacy Service

  • Potential for harm · D September 4, 2024

    Ensure that residents are free from significant medication errors.

    Corrected October 19, 2024 · Pharmacy Service

  • Potential for harm · E September 4, 2024 · found via complaint

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Corrected October 19, 2024 · Resident Rights

Federal penalties

DateTypeAmount / length
October 23, 2025Fine$14,069
October 23, 2025Payment Denial16 days

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 28E173 · certified since June 1, 1981. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.