ElderGrade

Inspection citations at Legacy Square

11 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 4 0
2025 4 1
2024 3 0
D January 15, 2026 Tag F0580 Corrected Mar 2026

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

F January 15, 2026 Tag F0882 Corrected Mar 2026

Infection Control Deficiencies

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

No actual harm, potential for more than minimal harm

F January 15, 2026 Tag F0880 Corrected Mar 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F January 15, 2026 Tag F0812 Corrected Mar 2026

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

D October 23, 2025 Tag F0610 Complaint investigation Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D October 23, 2025 Tag F0609 Complaint investigation Corrected Dec 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

F October 23, 2025 Tag F0868 Complaint investigation Corrected Dec 2025

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

J October 23, 2025 Tag F0689 Complaint investigation Corrected Dec 2025

Quality of Life and Care Deficiencies

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

Immediate jeopardy to resident health or safety

D September 4, 2024 Tag F0760 Corrected Oct 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D September 4, 2024 Tag F0759 Corrected Oct 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

E September 4, 2024 Tag F0550 Complaint investigation Corrected Oct 2024

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.