Report
TheVardellReport
Legacy Square
Nursing facility
1621 Front Street
Henderson, NE 68371
Report
← Legacy Square, free profile
Life by Vardell Presents
The Vardell Report.Legacy Square
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Henderson, NE
- Record Period
- 2023–2026
- Source Documents
- 6
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 4 inspections from September 2023 to January 2026, state surveyors documented 11 findings at Legacy Square; 11 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 4
- 2023–2026, standard and complaint
- Findings
- 11
- Deficiencies cited by state inspectors
- Corrected
- 11
- Of 11 findings, with a recorded correction date
- Penalties
- 2
- 1 fine; payment not published, 1 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 0 | 0 |
| 2024 | 1 | 3 | 0 |
| 2025 | 1 | 4 | 1 |
| 2026 | 1 | 4 | 0 |
What the Record Shows
- 11 of 11 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 1 fine of $14,069, its payment not published; denial of payment imposed October 23, 2025, ended December 7, 2025.
- 2 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, January 15, 2026, recorded 4 findings (most serious: Level F).
Report at a Glance
- Facility
- Legacy Square
- Address
- 1621 Front Street, Henderson, NE 68371
- CMS Certification Number
- 28E173
- Provider Type
- Nursing facility
- Certified Beds
- 40
- Ownership
- For profit - Corporation
- Record Window
- September 6, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
4 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 1, 2026
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Mar 1, 2026
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Mar 1, 2026
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Mar 1, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
4 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Dec 7, 2025
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Dec 7, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Dec 7, 2025
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 7, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
3 findings
The same visit included a complaint investigation.
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Oct 19, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Oct 19, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 19, 2024
Enforcement Action
Civil money penalty, $14,069 imposed October 23, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 4, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed October 23, 2025. Status: Closed, December 7, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 4, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
No citation repeats across the 4 inspections in this window, and no finding is waiting on a verified correction. That is what the record shows; it is not a judgment of care. The questions that follow still apply.
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 02
What led to the 2025 fine, and has it been paid?
A $14,069 civil money penalty was imposed October 23, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Nebraska state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Sep 6, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Sep 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Oct 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Jan 15, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 28E173
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowSeptember 6, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before September 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.