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LEGENDARY HEALTH CARE CENTER Inspection Report, Violations & Safety Grade (MARSHALL, Missouri)

809 EAST GORDON ST, MARSHALL, Missouri 65340

Phone: 6608862247

CMS Overall:1/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

43.5

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Saline

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing1/5

Quality2/5

Nurse Staffing Check

Metric	This Facility	Missouri Avg	Difference
RN Hours per Resident per Day	0.29	0.46	-0.17
Total Nurse Hours per Resident per Day	2.10	3.40	-1.30
CMS Staffing Rating	1/5	2.2/5	-
Nursing Staff Turnover	N/A	56.9%	-

Health Citation History

42 health citations on record

Date	Category	Description	Severity
2026-01-07	Administration Deficiencies	Administer the facility in a manner that enables it to use its resources effectively and efficiently.	E – Moderate Harm Potential
2026-01-07	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2025-05-20	Quality of Life and Care Deficiencies	Provide care or services that was trauma informed and/or culturally competent.	G – Actual Harm
2025-05-20	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2025-05-20	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2025-05-20	Resident Rights Deficiencies	Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.	E – Moderate Harm Potential
2025-05-20	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	E – Moderate Harm Potential
2025-05-20	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2025-05-20	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2025-05-20	Environmental Deficiencies	Keep all essential equipment working safely.	E – Moderate Harm Potential
2025-05-20	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	E – Moderate Harm Potential
2025-05-20	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2025-05-20	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	D – Moderate Harm Potential
2025-05-20	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2025-05-20	Nursing and Physician Services Deficiencies	Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.	D – Moderate Harm Potential
2025-05-20	Nursing and Physician Services Deficiencies	Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.	D – Moderate Harm Potential
2025-05-20	Resident Rights Deficiencies	Give residents a notice of rights, rules, services and charges.	C – Minimal Harm Potential
2025-05-20	Resident Rights Deficiencies	Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.	C – Minimal Harm Potential
2025-05-20	Resident Rights Deficiencies	Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.	C – Minimal Harm Potential
2025-05-20	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	B – Minimal Harm Potential
2025-03-04	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	J – Immediate Jeopardy
2023-11-16	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2023-10-12	Nutrition and Dietary Deficiencies	Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.	D – Moderate Harm Potential
2023-08-11	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-08-11	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2023-08-11	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	E – Moderate Harm Potential
2023-08-11	Resident Rights Deficiencies	Ensure residents have reasonable access to and privacy in their use of communication methods.	E – Moderate Harm Potential
2023-08-11	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2023-08-11	Nursing and Physician Services Deficiencies	Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.	E – Moderate Harm Potential
2023-08-11	Pharmacy Service Deficiencies	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	E – Moderate Harm Potential
2023-08-11	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2023-08-11	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	E – Moderate Harm Potential
2023-08-11	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2023-08-11	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2023-08-11	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	D – Moderate Harm Potential
2023-08-11	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2023-08-11	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2023-08-11	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	D – Moderate Harm Potential
2023-08-11	Nutrition and Dietary Deficiencies	Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.	D – Moderate Harm Potential
2023-08-11	Resident Rights Deficiencies	Assure the security of all personal funds of residents deposited with the facility.	C – Minimal Harm Potential
2019-12-03	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2019-12-03	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential

Fire Safety Citation History

32 fire safety citations on record

Date	Category	Description	Severity
2025-05-20	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2025-05-20	Construction Deficiencies	Meet other general requirements.	E – Moderate Harm Potential
2025-05-20	Smoke Deficiencies	Have an enclosure around a vertical opening shaft.	E – Moderate Harm Potential
2025-05-20	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2025-05-20	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	E – Moderate Harm Potential
2025-05-20	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	D – Moderate Harm Potential
2023-08-11	Emergency Preparedness Deficiencies	Create arrangements with other facilities to receive patients.	F – Moderate Harm Potential
2023-08-11	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	F – Moderate Harm Potential
2023-08-11	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	F – Moderate Harm Potential
2023-08-11	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	F – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Have an enclosure around a vertical opening shaft.	F – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2023-08-11	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2023-08-11	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	F – Moderate Harm Potential
2023-08-11	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2023-08-11	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2023-08-11	Egress Deficiencies	Install proper backup exit lighting.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	E – Moderate Harm Potential
2023-08-11	Smoke Deficiencies	Meet other general requirements.	E – Moderate Harm Potential
2019-12-03	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	F – Moderate Harm Potential
2019-12-03	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	F – Moderate Harm Potential
2019-12-03	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2019-12-03	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2019-12-03	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2019-12-03	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2019-12-03	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	E – Moderate Harm Potential

Total Penalties & Fines

$93,208

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-05-20	Fine	$55,443	-
2025-05-20	Payment Denial	-	8 days starting 2025-06-26
2025-03-04	Fine	$37,765	-

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Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the MARSHALL area at no cost.

Find Safe, Vetted Facilities Near MARSHALL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.