Legacy Square faces challenges in its CMS ratings, earning a D grade with a score of 49/100. The facility ranks in the 40th percentile among Nebraska nursing homes, suggesting significant room for improvement.
Staffing at Legacy Square is near the national average, with 3.95 total nursing hours per resident per day (national average: 3.8 hours).
Recent CMS inspections identified 9 deficiencies at Legacy Square, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.95 | 3.8 | Average |
| Registered Nurses (RN) | 0.82 | 0.7 | Above Average |
| Licensed Practical Nurses (LPN) | 0.70 | 0.7 | Average |
| Certified Nursing Assistants (CNA) | 2.43 | 2.4 | Average |
| Weekend Total Nursing | 3.28 | 3.8 | Below Average |
| Weekend RN Hours | 0.44 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0689 Severity JEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Oct 22, 2025 · Quality of Life and Care Deficiencies
- Tag 0868 Severity FHave the Quality Assessment and Assurance group have the required members and meet at least quarterlyOct 22, 2025 · Administration Deficiencies
- Tag 0609 Severity DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Oct 22, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0610 Severity DRespond appropriately to all alleged violations.Oct 22, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0550 Severity EHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Sep 3, 2024 · Resident Rights Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 1.5% | 4.5% | Better |
| Falls with major injury | 2.2% | 3.0% | Better |
| On antipsychotic medication | 13.3% | 14.5% | Average |
| Urinary tract infections | 4.5% | 2.5% | Worse |
| ADL decline (daily activities) | 25.2% | 14.0% | Worse |
| Excessive weight loss | 0.8% | 7.5% | Better |
| New/worsened incontinence | 20.1% | 45.0% | Better |
⚠️ Penalties & Fines
1 penalty recorded by CMS
Total fines: $21,645
How This Grade Was Calculated
This facility's grade of D is based on a score of 49 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 2★ → 16 pts (max 40)
- Health Inspection Rating: 1★ → 5 pts (max 25)
- Staffing Rating: 5★ → 20 pts (max 20)
- Quality Measures Rating: 5★ → 15 pts (max 15)
- Penalty deductions: -5 pts
- Fine deductions: -2 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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