Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Legendary Health Care Center during CMS and state inspections, most recent first.
Facility administration failed to maintain an effective system to ensure adequate incontinence supplies and gloves were available, resulting in multiple residents lacking appropriate briefs and room-stock gloves despite care plans requiring their use. Several residents with urinary and bowel incontinence reported going without briefs or being given briefs that were too small when the correct sizes were unavailable, leading to repeated incontinent episodes and clothing changes. Observations showed storage rooms stocked only with small and medium briefs even though many residents required larger sizes, and numerous occupied rooms had no gloves while gloves were centralized at the nurse’s station. Staff across multiple roles reported that since late summer the facility had ongoing low supplies of briefs, wipes, and gloves, that residents sometimes went without briefs or wore smaller sizes, and that gloves were removed from rooms when supplies were low. The DON and Administrator acknowledged persistent supply issues, reliance on staff reporting and morning meetings to identify shortages, and delays in ordering and approval processes that contributed to running out of needed items.
A resident with a history of atrial fibrillation and atrial flutter had an active order and care plan for daily Xarelto 15 mg, but staff failed to administer the anticoagulant for six consecutive days, documenting only that they were awaiting the medication. An LPN found the drug unavailable in the cart or emergency kit and informed the charge nurse, but neither notified the pharmacy promptly or contacted the physician, DON, or administrator about the missed doses. Pharmacy messages indicated an updated order was needed and later that the existing order was too old to refill, yet there was no documentation that an updated order was sent during that period. The DON reported she was not informed of the missed doses and confirmed that staff did not notify the physician or on-call physician, while the resident reported going without the blood thinner for several days and the physician stated he was unaware the resident had gone multiple days without the ordered anticoagulant.
A resident experienced an unwitnessed fall resulting in increased pain, dizziness, and a fractured hip. Despite the resident's complaints and requests to go to the hospital, staff failed to perform necessary neurological checks or notify the physician. Instead, an RN ordered an x-ray without a physician's order. The resident's condition worsened, leading to vomiting, unresponsiveness, and eventual death. The facility did not adhere to its protocols for assessing and reporting changes in the resident's condition.
Failure to Maintain Adequate Incontinence Supplies and Gloves for Resident Care
Penalty
Summary
Facility administration failed to implement an effective system to ensure sufficient incontinence supplies and gloves were available to meet residents’ needs. The facility had no policy regarding maintaining sufficient supplies, and the census was 37. Observations on the day of survey showed multiple resident rooms without gloves and without appropriate incontinence briefs, despite care plans requiring the use of briefs and peri-care after incontinence episodes. Central storage rooms contained only small and medium incontinence briefs and pull-ons, while the posted resident list showed that no residents required small briefs and multiple residents required large, extra-large, triple extra-large, and quadruple/quintuple extra-large sizes, which were not in stock. One resident with frequent urinary incontinence, who required staff assistance with ADLs and wore size five-X incontinence briefs, was observed without an incontinence brief and with only one brief two sizes too small available at bedside. There were no gloves in this resident’s room. The resident reported that incontinence supplies had been low for two months, that the facility was out of briefs in the correct size, and that he/she had gone without briefs when the facility was out. The resident stated staff had brought a brief two sizes too small that could not be worn, and described having multiple incontinent episodes over the previous two days, requiring clothing changes due to lack of briefs, and feeling humiliated when incontinent without a brief. The DON confirmed this resident had not had incontinence briefs for four days. Another resident with some incontinence, whose care plan required assistance with toileting hygiene, peri-care, and use of incontinence briefs as needed, had no gloves or incontinence briefs in the room. This resident stated he/she wore briefs when the facility had them, went without when they ran out, and had been told that large briefs were unavailable that day, resulting in not wearing a brief. A third resident, frequently incontinent of bowel and bladder and care planned for peri-care with each brief change, also had no gloves or briefs in the room. This resident reported the facility had run out of his/her size briefs two weeks earlier, that staff had put on a brief that was too small, and that an incontinent episode the previous day required a clothing change because the brief was too small. Staff interviews corroborated that this resident’s correct size had been unavailable and that smaller briefs were used instead. Additional observations showed no gloves in another resident’s room, with that resident stating staff brought gloves in their pockets when providing care. There were no gloves on the medication cart at the nurse’s station, and multiple occupied rooms lacked gloves, while boxes of gloves were kept at the nurse’s station. Multiple CNAs, CMTs, and an RN reported that since August the facility had ongoing issues with low supplies of gloves, incontinence briefs, and wipes, including running out of larger brief sizes. Staff stated residents sometimes went without briefs or were placed in smaller sizes, and that gloves were removed from rooms and kept at the nurse’s station when supplies were low, with staff carrying gloves in their pockets. The DON stated she was responsible for ordering supplies twice a month and was supposed to complete daily inventory but actually did so every other day. She said staff were expected to report low supplies so that items could be purchased locally or increased on the next order, and that supply issues were discussed daily in morning meetings. She acknowledged she was not aware the facility was completely out of larger briefs until staff reported it on the survey date, and that when glove supplies were low, gloves were kept at the nurse’s station and staff were expected to take handfuls and keep them in their pockets or on carts, even though this was an infection control issue. The Administrator acknowledged ongoing issues with running low or out of supplies, attributed to higher usage of gloves and briefs and an insufficient established supply, and stated he relied on staff notification and morning meetings to monitor supply levels, and was aware that gloves and briefs were low on the survey date.
Failure to Administer Ordered Anticoagulant and Notify Physician When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of care and physician orders for anticoagulant therapy for one resident. The resident had diagnoses of atrial fibrillation and atrial flutter and a physician’s order, originally dated 6/27/25 and active in December 2025, for Xarelto 15 mg to be given once daily in the evening. The resident’s care plan, dated 7/7/25, documented that the resident was on anticoagulant therapy related to atrial fibrillation and directed staff to administer anticoagulant medications as ordered. Review of the December 2025 MAR showed that Xarelto was not administered on six consecutive days (12/11/25 through 12/16/25), with staff documenting that they were awaiting the medication on all six days. Staff interviews revealed multiple failures to obtain and administer the ordered medication and to follow required notification processes. One LPN reported that on 12/11/25 Xarelto was not available in the medication cart or emergency kit, and although this was reported to the charge nurse, the LPN did not notify the pharmacy, physician, DON, or administrator and was unsure of the pharmacy process when a medication was unavailable. The charge nurse (another LPN) confirmed that Xarelto was not available on 12/11/25, stated that he/she usually did not contact the pharmacy and believed CMTs were responsible for that task, and acknowledged that he/she did not notify the physician or on-call physician that the medication was not available or not administered. The charge nurse stated that a request to the pharmacy was sent on 12/12/25 and that the resident did not receive Xarelto from 12/11/25 through 12/16/25. Review of the communication platform between the facility and the pharmacy showed that on 12/12/25 the pharmacy requested an updated order for Xarelto following the resident’s readmission, and on 12/15/25 the pharmacy again indicated it could not refill the medication because the order was over a year old and requested an updated order. There was no documentation in the resident’s progress notes that an updated order was sent to the pharmacy between 12/12/25 and 12/15/25. The DON stated she was not informed that the resident had missed Xarelto doses from 12/11/25 through 12/16/25, was not aware of the process for reinstating an order with the pharmacy until this case, and confirmed that staff did not notify the physician or on-call physician when the resident did not receive Xarelto during that period. The resident reported going without his/her blood thinner for five to six days in December, and the physician stated the resident was to receive an anticoagulant daily for atrial flutter and stroke prevention and that staff did not notify him/her that the resident went six days without the anticoagulant.
Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
The facility failed to thoroughly assess a resident and notify the physician after the resident sustained an unwitnessed fall. The resident experienced increased pain, dizziness, vomiting, and a fractured hip following the fall. Despite these symptoms, the staff transferred the resident multiple times, causing the resident to yell and scream in pain. Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B did not perform necessary neurological checks or report the resident's condition to the physician. Instead, RN A ordered an x-ray without a physician's order, and the resident eventually lost consciousness and died at the facility. The facility's policies required staff to assess and document vital signs, injuries, and neurological status after a fall, especially if unwitnessed. Staff were also expected to notify the physician and follow up on any fall with associated injury until the resident was stable. However, RN A and LPN B did not adhere to these protocols. RN A did not complete neurological assessments and failed to notify the on-call physician, while LPN B did not notify the physician of the resident's pain and changes in condition. Interviews with staff revealed that the resident repeatedly expressed pain and requested to go to the hospital, but these requests were not acted upon. The resident's condition deteriorated, leading to vomiting and unresponsiveness. Emergency Medical Services (EMS) were called, but the resident was found to be unresponsive and without a pulse upon their arrival. The facility's failure to follow established protocols and communicate effectively with medical professionals contributed to the resident's decline and eventual death.
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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.
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Nursing homes near Marshall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Living Center, The | 1.9 mi | ★★★★★ | 0 | 0 |
| Apple Ridge Care Center | 19.2 mi | ★★★★★ | 5 | 0 |
| Glasgow Gardens | 20.5 mi | ★★★★★ | 0 | 0 |
| Brunswick Health Care Center | 22 mi | ★★★★★ | 0 | 0 |
| Katy Manor | 22 mi | ★★★★★ | 0 | 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.