Legendary Health Care Center, Marshall, MO

The Essentials

Summary

Across 7 inspections from December 2019 to January 2026, state surveyors documented 42 findings at Legendary Health Care Center; 42 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections: 7; 2019–2026, complaint and standard
Findings: 42; Deficiencies cited by state inspectors
Corrected: 42; Of 42 findings, with a recorded correction date
Penalties: 3; 2 fines; payment not published, 1 closed

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2019	1	2	0
2020	0	0	0
2021	0	0	0
2022	0	0	0
2023	3	19	0
2024	0	0	0
2025	2	19	2
2026	1	2	0

What the Record Shows

42 of 42 findings have a recorded correction date.
CMS lists 3 enforcement actions in the window: 2 fines totaling $93,208, their payment not published; denial of payment imposed May 20, 2025, ended July 4, 2025.
4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, May 20, 2025, recorded 18 findings (most serious: Level G).

What to Ask About

Professional Standards, Cited in Three Inspections
Infection Control, Cited in Three Inspections
Quality of Care, Cited in Two Inspections
Accident Hazards and Supervision, Cited in Two Inspections
Medication Labeling and Storage, Cited in Two Inspections
Citation F808, Cited in Two Inspections
Kitchen and Food Safety, Cited in Two Inspections

Report at a Glance

Facility: Legendary Health Care Center
Address: 809 East Gordon St, Marshall, MO 65340
CMS Certification Number: 265508
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 92
Ownership: For profit - Limited Liability company
Record Window: December 3, 2019 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.

Jan 72026
Complaint investigation
2 findings
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Jan 26, 2026
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 26, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 202025
Standard health inspection
18 findings
- F699Provide care or services that was trauma informed and/or culturally competent.Level GActual harmCorrected Jul 4, 2025
- 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 Jul 4, 2025
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jul 4, 2025
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level ENo actual harm, potential for moreCorrected Jul 4, 2025
- F585Honor 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.Level ENo actual harm, potential for moreCorrected Jul 4, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jul 4, 2025
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Jul 4, 2025
- F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Jul 4, 2025
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Jul 4, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 4, 2025
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Jul 4, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 4, 2025
- F728Ensure 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.Level DNo actual harm, potential for moreCorrected Jul 4, 2025
- F729Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.Level DNo actual harm, potential for moreCorrected Jul 4, 2025
- F572Give residents a notice of rights, rules, services and charges.Level CPotential for minimal harmCorrected Jul 4, 2025
- F575Post 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.Level CPotential for minimal harmCorrected Jul 4, 2025
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Jul 4, 2025
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level BPotential for minimal harmCorrected Jul 4, 2025
Enforcement Action
Civil money penalty, $55,443 imposed May 20, 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 May 20, 2025, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed May 20, 2025. Status: Closed, July 4, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 20, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Mar 42025
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Mar 5, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nov 162023
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 14, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 122023
Complaint investigation
1 finding
- F808Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 3, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Aug 112023
Standard health inspection
17 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 Sep 25, 2023
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 3, 2023
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
- F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
- F727Have 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.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
- F758Implement 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.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Nov 3, 2023
- F803Ensure 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.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Sep 25, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 14, 2023
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 25, 2023
- F808Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 3, 2023
- F570Assure the security of all personal funds of residents deposited with the facility.Level CPotential for minimal harmCorrected Sep 25, 2023
Enforcement Action
Civil money penalty, $37,765 imposed March 4, 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 August 11, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Dec 32019
Standard health inspection
2 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 17, 2020
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 17, 2020
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.

1
Professional Standards, Cited in Three Inspections
Inspectors cited F658 in December 2019, May 2025 and January 2026. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232323252526F658 across all 7 inspections, oldest to newest
2
Infection Control, Cited in Three Inspections
Inspectors cited F880 in December 2019, August 2023 and May 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232323252526F880 across all 7 inspections, oldest to newest
3
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in August 2023 and March 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232323252526F684 across all 7 inspections, oldest to newest
4
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in August 2023 and November 2023. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232323252526F689 across all 7 inspections, oldest to newest
5
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in August 2023 and May 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232323252526F761 across all 7 inspections, oldest to newest
6
Citation F808, Cited in Two Inspections
Inspectors cited F808 in August 2023 and October 2023. The agency describes it this way: 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232323252526F808 across all 7 inspections, oldest to newest
7
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in August 2023 and May 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19232323252526F812 across all 7 inspections, oldest to newest

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 do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in three inspections, most seriously at level D.
02
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level F.
03
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level J.
04
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level D.
05
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level E.
06
What changed after F808 was cited, and how do you check it now?
Citation F808: cited in two inspections, most seriously at level D.
07
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
08
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.
09
What led to the 2025 fine, and has it been paid?
A $55,443 civil money penalty was imposed May 20, 2025. CMS publishes the fine, not whether it has been paid. The record holds three 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 Missouri state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Dec 3, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Aug 11, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Oct 12, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Nov 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Mar 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection May 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Missouri state survey agency
Inspection Jan 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 265508
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowDecember 3, 2019 – October 1, 2026

CMS publishes about three inspection cycles; inspections before December 2019 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.