Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy Square during CMS and state inspections, most recent first.
A dietary aide repeatedly handled and plated food in the kitchenettes while wearing gloves without performing hand hygiene before gloving, after removing gloves, or between tasks, and also used gloved hands to touch multiple food items, utensils, and a computer tablet. Surveyors also observed another dietary aide with a hair restraint that did not fully cover the hair while food was on the steam table and counter. The aide and the DON acknowledged the expected hand hygiene, glove use, and hair restraint practices.
The facility failed to prevent cross-contamination of COVID-19 among multiple residents during an outbreak. Records showed positive cases spread across the building, while the ICC could not provide case tracking or trending and had limited time for the IPP role. Staff interviews confirmed masking was optional, and observations showed staff not wearing masks in hallways, dining areas, the kitchen, and resident rooms except for the rooms of two COVID-positive residents. The AA confirmed 10 resident cases and acknowledged the facility could and should have done more to prevent spread.
The facility failed to designate a dedicated infection preventionist responsible for the infection prevention and control program who worked at least part-time in LTC. The ICC also served as Lab Supervisor and had other hospital duties, stated they tried to devote about five hours per week to the IP role but did not often get to LTC, and denied access to resident records for infection monitoring. Records showed all ICC hours were coded to the hospital, and leadership confirmed there was no allocation of ICC hours to LTC.
A resident fell in the bath house and sustained an abrasion to the elbow and right hip pain, with Tylenol given for pain rated 6/10. The resident had a history of falls, was receiving PT for gait concerns, and the MDS documented a fall with injury and fall-related pain. The DON confirmed the physician was not notified immediately, and the AA confirmed there was no facility notification policy.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised due to a malfunctioning WanderGuard bracelet. Staff were unaware of the resident's absence until the individual was observed outside and brought back in. The care plan lacked specific interventions for exit-seeking, and staff had not received adequate training on new safety devices. The incident was not reported or investigated as an elopement, and there was no follow-up assessment or family notification.
The QAA committee did not include all required members, as the Medical Director failed to attend any quarterly meetings over the past year, and both the DON and Administrator were absent from one meeting. These attendance issues were confirmed by facility leadership.
A resident with severe cognitive impairment and a history of wandering was found outside the facility unattended, but the incident was not investigated or reported to APS or DHHS as required. Facility staff did not complete an assessment or incident report, and leadership confirmed the event was not reported to state agencies.
A resident with severe cognitive impairment and a history of wandering was found outside the building unattended, despite being identified as high risk and wearing a Wanderguard. Staff did not recognize the event as an elopement, failed to complete an incident report, and did not conduct an investigation or assessment, contrary to facility policy.
The facility failed to uphold resident rights, as two residents with dementia frequently wandered into others' rooms, causing distress and safety concerns. Despite interventions like redirection and one-on-one activities, these measures were ineffective in preventing privacy violations.
A long-term care facility reported a medication error rate of 19.35%, exceeding the acceptable threshold of 5%. Errors included improper administration of insulin and eye drops for three residents. An RN failed to hold insulin pens in place for the required time and administered eye drops incorrectly, while an LPN improperly administered eye drops without applying pressure to the tear duct.
A registered nurse in the facility failed to follow proper insulin pen administration procedures, resulting in significant medication errors for two residents. The nurse did not hold the needle in the skin for the required duration after injection, as specified in the manufacturer's instructions, leading to incomplete delivery of insulin doses.
Hand Hygiene and Hair Restraint Lapses During Meal Service
Penalty
Summary
The facility failed to ensure hand hygiene was completed and hair was restrained during meal service. Surveyors cited observations in the Slate and Sun kitchenettes showing a dietary aide repeatedly handling food while wearing gloves without performing hand hygiene before donning gloves, after removing gloves, or between tasks. The aide cracked and fried eggs, plated food, handled waffles, sausage patties, scrambled eggs, fruit, bread, toast, prune juice, and other items, and used a knife while gloved, without changing gloves or cleaning hands between activities. In one observation, the dietary aide applied gloves, cooked an egg, plated it, removed the gloves without hand hygiene, and served the tray. In later observations, the aide again put on gloves without hand hygiene and handled multiple foods and kitchen items, including reaching into food containers, touching a computer tablet screen, and moving between the stove, serving line, and tray assembly without changing gloves or washing hands. The aide later removed gloves and took the tray to the dining room without hand hygiene. During interview, the aide acknowledged that hands should be washed and the ABCs sung every time gloves are removed and before putting on new gloves, and also stated that food should be handled with utensils or tongs rather than gloved hands. Surveyors also observed a dietary aide in the Slate kitchenette with a hair restraint that did not cover all of the aide's hair while food was in the steam table and on the counter. The aide confirmed the hair restraint should cover all of the hair. The Director of Nutrition confirmed that kitchen staff should not grab food with gloved hands and should use tongs, and that hair restraints should cover hair. The facility census was 33, and the report states the failure had the potential to affect all 32 residents receiving meals from the kitchen.
Failure to Prevent COVID-19 Spread Among Residents
Penalty
Summary
The facility failed to prevent cross-contamination of COVID-19 among 10 sampled residents, including residents 2, 3, 8, 12, 14, 15, 18, 22, 24, and 30, out of 22 sampled residents in a census of 33. The record review showed a COVID tracking log documenting positive tests beginning with resident 15 on 12/21/2025 and continuing with additional residents testing positive through 1/14/2026. The facility assessment stated that infection prevention and control would identify, contain, and prevent infections, but the infection control meeting minutes only noted increased monitoring for flu, norovirus, and COVID after the facility had a current COVID outbreak, with no other COVID-related measures documented to prevent spread. The Infection Control Coordinator confirmed the outbreak began in December 2025, could not provide the actual number of COVID cases or tracking and trending of resident cases, and stated staff were encouraged to wear masks after the first case. The coordinator also stated they did not have access to resident records to audit or monitor documentation for signs or symptoms of infection and had multiple other duties, limiting time in the IPP role. Staff interviews confirmed masking was optional during the outbreak, and observations from 1/13/2026 through 1/15/2026 showed staff not wearing masks in public hallways, dining areas, the kitchen, and resident rooms except for the rooms of two COVID-positive residents. The Assistant Administrator confirmed there were 10 resident COVID cases, that the first case was on 12/21/2025, and that the facility could and should have done more to prevent the spread of COVID infection.
Failure to Designate Dedicated Infection Preventionist
Penalty
Summary
The facility failed to designate a dedicated staff member as the infection preventionist responsible for the infection prevention and control program who worked at least part-time in the nursing home. The cited deficiency was based on interviews and record reviews involving the Laboratory Supervisor/Infection Preventionist job description, which listed responsibilities for identifying, investigating, reporting, preventing, and controlling infections and communicable diseases within the organization. The job description was signed by the Infection Control Coordinator (ICC) and reported to the CNO and QAC. During interview, the ICC stated that the role included following CDC guidance, but also that the ICC had other duties as Lab Supervisor, ICC, and Safety Committee member for the hospital, including LTC. The ICC said they tried to devote at least five hours per week to the infection preventionist role but did not get over to LTC often because of other duties, and denied having access to resident records to audit or monitor documentation for signs or symptoms of infection. Record review showed the ICC timecard hours from 10/1/2025 through 1/15/2026 were all coded to [NAME] Health Care Services, Inc., and the HRD confirmed all ICC hours were allocated to the hospital and not LTC. The HRD also confirmed the hospital payroll system was not set to differentiate ICC hours for LTC, and the QAC confirmed supervising the ICC role with no allocation of ICC hours to LTC as required.
Failure to Notify Physician After Resident Fall With Injury and Pain
Penalty
Summary
The facility failed to notify the physician of a resident fall that involved an abrasion to the right elbow and right hip pain with Tylenol given for pain rated 6 out of 10. Resident 17 was cognitively intact with a BIMS score of 15, had a diagnosis of heart failure, and had a history of falls noted in the care plan. Facility records showed the resident was receiving physical therapy for gait concerns related to fall history, and the incident report documented that the resident fell in the bath house and was alert and oriented afterward. Record review showed the resident's quarterly MDS marked one fall with injury, including abrasions and fall-related pain. The facility's incident report summary and progress note both documented the fall, the abrasion, and the hip pain, but the physician was not notified immediately. During interview, the DON confirmed the physician was not notified right away because the resident was not injured, though the DON stated the resident maybe should have been notified due to hip pain. The AA also confirmed there was no facility notification policy, and an undated form indicated the resident's doctor did not want to be notified of occurrences requiring no first aid or occurrences requiring first aid.
Failure to Prevent Elopement Due to Equipment Malfunction and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia exited the facility without staff knowledge. The resident was identified as high risk for wandering and had a history of exit-seeking behaviors. The resident was wearing a WanderGuard bracelet, which was checked and found to be working earlier in the morning, but later malfunctioned, allowing the resident to leave the building. Staff observed the resident outside and assisted them back into the facility, but there was no documentation of how long the resident was outside or a nursing assessment following the incident. The facility's policies required staff to be knowledgeable about elopement procedures and to document elopement risk, WanderGuard bracelet status, and any incidents or malfunctions. However, the care plan for the resident only included checking the WanderGuard function every shift, with no other interventions for exit-seeking or elopement risk. Staff interviews revealed a lack of awareness and training regarding new safety devices, such as a motion detector installed after the incident, and no one was assigned responsibility for monitoring it. Additionally, exit doors and alarms were not routinely checked for functionality unless a problem was reported, and the motion detector was found to be nonfunctional during the survey. Communication and reporting failures were also identified. The incident was not reported as an elopement, and there was no follow-up assessment or notification to the resident's family. Staff members, including the DON and AA, were unclear about the details of the incident, and there was no documentation of extra checks or interventions for the resident after the event. The lack of investigation and reporting, combined with equipment failures and insufficient staff training, contributed to the deficiency.
QAA Committee Lacked Required Member Participation
Penalty
Summary
The facility administrator failed to ensure that the Quality Assessment and Assurance (QAA) committee included all required members and that these members attended the quarterly meetings as mandated. Record review showed that the facility's Medical Director did not participate in any of the quarterly QAA meetings for the past four quarters. Additionally, on one occasion, both the Director of Nursing (DON) and the Administrator were absent from a quarterly QAA meeting. These findings were confirmed through interviews with the Assistant Administrator and the Administrator, who acknowledged the lack of documentation and attendance by the required committee members. The facility census at the time of the survey was 37 residents. There is no mention of specific residents or their medical conditions being directly affected in the report.
Failure to Report Elopement Incident Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to report an incident of elopement involving a resident with severe cognitive impairment and a history of wandering. According to the facility's own algorithm, incidents of elopement require completion of an incident report, documentation in the resident's medical record, and submission of the investigation to the Department of Health and Human Services (DHHS). However, review of facility records showed no documentation or reporting of any elopement incidents in the past 12 months, despite progress notes indicating that the resident was found outside the building. Interviews with facility staff revealed that the incident was not investigated or reported to Adult Protective Services (APS) or DHHS. The Assistant Administrator stated that the event was not considered an elopement and no assessment was completed because there was no visible injury. The Director of Nursing was unaware of how long the resident was outside unattended and confirmed that the resident should not have been outside alone. The Administrator acknowledged that the incident was not reported to state agencies as required.
Failure to Investigate Elopement Incident for High-Risk Resident
Penalty
Summary
The facility failed to thoroughly investigate an incident of elopement involving a resident with severe cognitive impairment and a history of wandering. The resident, who had a diagnosis of dementia, a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment, and was identified as high risk for wandering, was found outside the building unattended. The resident was wearing a Wanderguard, and facility policy defined elopement as any resident leaving the campus without informing staff. Despite this, the incident was not reported as an elopement, no incident report was completed, and no detailed notation was made in the resident's medical record as required by facility policy. Interviews with facility staff confirmed that the resident should not have been outside unattended and that the Wanderguard system was the only safeguard in place to prevent such incidents. The Assistant Administrator stated that no investigation or assessment was conducted because the incident was not considered an elopement and there was no visible injury. The Director of Nursing was unaware of how long the resident was outside, and the Administrator later confirmed that the incident should have been investigated as an elopement but was not. The facility's reportable investigations for the past 12 months did not include any elopements, despite this event.
Resident Wandering and Privacy Violations
Penalty
Summary
The facility failed to maintain the rights of its residents, particularly concerning privacy and safety, as evidenced by the repeated incidents involving Resident 6 and Resident 28. Both residents, diagnosed with dementia and exhibiting wandering behaviors, frequently entered other residents' rooms uninvited, causing distress and potential safety issues. Despite interventions such as redirection, offering food, and one-on-one activities, these measures were largely ineffective in preventing the intrusions. Resident 6, with a history of vascular dementia and anxiety, was noted to wander into other residents' rooms, often taking personal items and causing disturbances. This behavior led to confrontations with other residents, some of whom resorted to yelling or physical aggression to remove Resident 6 from their rooms. The facility's staff attempted various interventions, including redirection and monitoring, but these were insufficient to prevent the repeated violations of other residents' privacy and safety. Similarly, Resident 28, also diagnosed with dementia, exhibited wandering behaviors that intruded on the privacy of other residents. Despite care plan interventions aimed at diverting attention and redirecting Resident 28, the resident continued to enter other residents' rooms, sometimes setting off alarms or taking personal items. The facility's inability to effectively manage these behaviors resulted in ongoing disruptions and violations of resident rights, highlighting a significant deficiency in maintaining a safe and respectful environment for all residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 19.35% for three out of nine sampled residents. This deficiency was identified through record reviews, observations, and interviews. Specifically, the errors involved incorrect administration of insulin and eye drops, which were not given according to the prescribed instructions or physician orders. For Resident 3, the Registered Nurse (RN-J) administered Lantus, Humalog, and semiglutide insulin using injection pens but did not hold the needle in the skin for the required duration after pressing the injection button, as specified in the medication instructions. Additionally, RN-J administered artificial tears in both eyes instead of only the right eye as ordered. RN-J admitted to not being aware of the need to hold the pen in place for a specific time and confirmed the error in administering the eye drops. Resident 14 also received Lantus insulin from RN-J, who again failed to hold the needle in the skin for the required 10 seconds. For Resident 24, a Licensed Practical Nurse (LPN-E) administered Dorzolamide eye drops incorrectly by placing them in the inner canthus and immediately wiping the eye without applying pressure to the tear duct. These actions were confirmed as errors by the Minimum Data Set Coordinator during an interview.
Medication Administration Errors with Insulin Pens
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during the administration of insulin. Specifically, the report highlights that a registered nurse (RN-J) did not adhere to the proper administration techniques for insulin pens as outlined in the manufacturer's instructions. For Resident 3, RN-J administered Lantus, Humalog, and semiglutide without holding the needle in the skin for the required duration after pressing the injection button, which is necessary to ensure the full dose is delivered. The nurse admitted to not being aware of the need to hold the pen in place for a specific time after injection. Similarly, for Resident 14, RN-J administered Lantus insulin without holding the needle in the skin for the required 10 seconds. This oversight was confirmed during an interview with RN-J, who acknowledged not following the correct procedure. The facility's insulin pen administration policy was reviewed, which stated that insulin should be administered per package instructions, yet the nurse did not comply with these guidelines, leading to the medication errors.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 39 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Henderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sutton Community Home, Inc. | 11.8 mi | ★★★★★ | 9 | 0 |
| Memorial Community Care | 12.2 mi | ★★★★★ | 4 | 0 |
| Westfield Quality Care Of Aurora | 12.5 mi | ★★★★★ | 1 | 0 |
| York General Hearthstone | 13.3 mi | ★★★★★ | 5 | 0 |
| Fairview Manor | 15.3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.