Legacy Square
Open-data reference.
Legacy Square is a for profit - corporation facility in Henderson, NE with 40 certified beds and a 2-star overall CMS rating. The facility has 9 deficiency records on file. Total penalties: $22K.
1621 Front Street, Henderson, NE 68371
Phone: 4027235301
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 28E173
- Ownership
- For profit - Corporation
- Provider Type
- Medicaid
- Beds
- 40
- Residents
- 39
- In Hospital
- Yes
- County
- York
- Last Inspection
- Sep 4, 2024
Staffing Data
- RN Hours
- 0.82 (nat'l avg: 0.68)
- LPN Hours
- 0.70
- CNA Hours
- 2.43
- Total Nursing Hours
- 3.95 (nat'l avg: 3.89)
- PT Hours
- 0.00
- Nursing Turnover
- 42.9%
- RN Turnover
- 28.6%
What the CMS Record Reveals About Legacy Square
Legacy Square operates 40 certified beds in Henderson, NE with approximately 39 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (5★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 9 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $22K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.95 total nursing hours per resident day (national average 3.89), with RN coverage at 0.82 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicaid" provider embedded within a hospital campus, Legacy Square falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 42.9%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (9 most recent)
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Dec 7, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 7, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 7, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 7, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Oct 19, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Oct 19, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Oct 19, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 14, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 14, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 25.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 4.5% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 97.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 92.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | N/A | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.9% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 6.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 20.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 13.3% | Yes |
Penalty History 1 penalties totaling $22K
No penalties on record.
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Understanding Nursing Home Data
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for Legacy Square?
What are the staffing levels at Legacy Square?
How many beds does Legacy Square have?
Does Legacy Square have any deficiencies on record?
Has Legacy Square received any fines or penalties?
Who owns Legacy Square?
When was Legacy Square last inspected?
What quality measures are tracked for Legacy Square?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.