Legendary Health Care Center

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 2.7 to 2.1 hours per resident per day.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Fine

  CMS changed the fine from May 20, 2025 from $54,431 to $55,443.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.2 to 1.8 hours per resident per day.

• Name

  CMS lists a new name for this home. It was LEGENDARY NURSING & REHABILITATION LLC.

• Fine

  CMS changed the fine from May 20, 2025 from $83,740 to $54,431.

CMS lists this as a complaint inspection.

• Citation F0835. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on January 26, 2026.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on January 26, 2026.

  CMS has cited this home for F0658 3 times since 2019.

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• Fine

  CMS changed the fine from March 4, 2025 from $58,100 to $0.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS stopped payment for new admissions from June 26, 2025, for 8 days.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

104 of 486 Missouri homes (21%) got a citation at the actual harm level in 2025.

• Citation F0699. Severity G: actual harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on July 4, 2025.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on July 4, 2025.

  CMS has cited this home for F0812 2 times since 2023.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 4, 2025.

  CMS has cited this home for F0880 3 times since 2019.

• Citation F0568. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

  CMS lists it as corrected on July 4, 2025.

• Citation F0585. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on July 4, 2025.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on July 4, 2025.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on July 4, 2025.

  CMS has cited this home for F0761 2 times since 2023.

• Citation F0908. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep all essential equipment working safely.

  CMS lists it as corrected on July 4, 2025.

• Citation F0947. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS lists it as corrected on July 4, 2025.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on July 4, 2025.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on July 4, 2025.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on July 4, 2025.

• Citation F0728. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on July 4, 2025.

• Citation F0729. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

  CMS lists it as corrected on July 4, 2025.

• Citation F0572. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Give residents a notice of rights, rules, services and charges.

  CMS lists it as corrected on July 4, 2025.

• Citation F0575. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on July 4, 2025.

• Citation F0577. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on July 4, 2025.

• Citation F0582. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  CMS lists it as corrected on July 4, 2025.

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CMS lists this as a standard inspection.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on July 4, 2025.

  CMS has cited this home for K0712 3 times since 2019.

• Citation K0100. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Meet other general requirements.

  CMS lists it as corrected on July 4, 2025.

• Citation K0311. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on July 4, 2025.

  CMS has cited this home for K0311 2 times since 2023.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on July 4, 2025.

  CMS has cited this home for K0363 2 times since 2023.

• Citation K0911. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on July 4, 2025.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on July 4, 2025.

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CMS fine of $55,443 on May 20, 2025.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 3 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.4 to 3.8 hours per resident per day.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

65 of 486 Missouri homes (13%) got a citation at the immediate jeopardy level in 2025.

• Citation F0684. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 5, 2025.

  CMS has cited this home for F0684 2 times since 2023.

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CMS fine of $37,765 on March 4, 2025.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 14, 2023.

  CMS has cited this home for F0689 2 times since 2023.

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CMS lists this as a complaint inspection.

• Citation F0808. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 3, 2023.

  CMS has cited this home for F0808 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 25, 2023.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 3, 2023.

• Citation F0561. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  CMS lists it as corrected on September 25, 2023.

• Citation F0576. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure residents have reasonable access to and privacy in their use of communication methods.

  CMS lists it as corrected on September 25, 2023.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 25, 2023.

• Citation F0727. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 25, 2023.

• Citation F0758. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 25, 2023.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 3, 2023.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 25, 2023.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on September 25, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 25, 2023.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on September 25, 2023.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on September 25, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 14, 2023.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on September 25, 2023.

• Citation F0808. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 3, 2023.

• Citation F0570. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Assure the security of all personal funds of residents deposited with the facility.

  CMS lists it as corrected on September 25, 2023.

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CMS lists this as a standard inspection.

• Citation E0025. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Create arrangements with other facilities to receive patients.

  CMS lists it as corrected on September 25, 2023.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on September 25, 2023.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on September 25, 2023.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on September 25, 2023.

• Citation K0311. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on November 16, 2023.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on September 25, 2023.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on September 25, 2023.

• Citation K0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on September 25, 2023.

• Citation K0161. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on September 25, 2023.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 25, 2023.

  CMS has cited this home for K0222 2 times since 2019.

• Citation K0281. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install proper backup exit lighting.

  CMS lists it as corrected on September 25, 2023.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on September 25, 2023.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on September 25, 2023.

  CMS has cited this home for K0353 2 times since 2019.

• Citation K0355. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on September 25, 2023.

• Citation K0362. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

  CMS lists it as corrected on September 25, 2023.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on September 25, 2023.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on September 25, 2023.

  CMS has cited this home for K0372 2 times since 2019.

• Citation K0374. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on September 25, 2023.

  CMS has cited this home for K0374 2 times since 2019.

• Citation K0932. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Meet other general requirements.

  CMS lists it as corrected on September 25, 2023.

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CMS lists this as a standard inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on January 17, 2020.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 17, 2020.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on January 17, 2020.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on January 17, 2020.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 17, 2020.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on January 17, 2020.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 17, 2020.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on January 17, 2020.

• Citation K0374. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on January 17, 2020.

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