Legendary Health Care Center
809 East Gordon St, Marshall, MO 65340 · Saline County · 92 certified beds · avg 42 residents/day · certified since Sep 4, 1992
Part of chain: RELIANT CARE MANAGEMENT (34 facilities, chain avg rating 1.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 4, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 5, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 20, 2025 · F-0699
The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Why it matters: Care that ignores a resident's trauma or culture can cause distress and damage their trust in caregivers.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 4, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (42)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 7, 2026 | E · Potential for harm, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Jan 7, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| May 20, 2025 | ▲ G · Actual harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| May 20, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 20, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| May 20, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 20, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not verify that its nurse aides had completed their required training, or did not retrain aides who had been out of nurse aide work for 2 years. |
| May 20, 2025 | C · Minimal risk, facility-wide | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. |
| May 20, 2025 | C · Minimal risk, facility-wide | The facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency. |
| May 20, 2025 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| May 20, 2025 | B · Minimal risk, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Mar 4, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 12, 2023 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · from a complaint |
| Aug 11, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 11, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Aug 11, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Aug 11, 2023 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Aug 11, 2023 | C · Minimal risk, facility-wide | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
| Dec 3, 2019 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 3, 2019 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (17 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 2 | 0 | D |
| 2023 | 19 | 0 | F |
| 2025 | 19 | 2 | J ▲ |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $93,208, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| May 20, 2025 | Fine | $55,443 |
| May 20, 2025 | Payment Denial | 8 days from Jun 26, 2025 |
| Mar 4, 2025 | Fine | $37,765 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.23 | 3.66 | 3.95 | bottom 9% in Missouri; bottom 2% in the U.S. |
| Registered Nurse hours | 0.27 | 0.49 | 0.69 | bottom 21% in Missouri; bottom 7% in the U.S. |
| Weekend total nurse staffing | 1.88 | 3.22 | 3.50 | bottom 8% in Missouri; bottom 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.33 | 0.48 | bottom 40% in Missouri; bottom 19% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 56.0 | 45.8 | — |
| RN turnover (%) | 0.0 | 47.8 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.75, RN 0.33, weekend 2.31. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company · changed ownership in the last 12 months
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Destefane, Richard | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/15/2025 |
| RCG INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/15/2025 |
| Reliant Care Group LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 08/15/2025 |
| Richard J. Destefane Revocable Living Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/15/2025 |
| Arshad, Abdullah | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2025 |
| Arshad, Abdullah | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2025 |
| Destefane, Richard | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2025 |
| Destefane, Richard | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2025 |
| Legendary Re Associates, L.L.C. | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2025 |
| Reliant Care Management Company LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/15/2025 |
| Reliant Care Management Company LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/28/2025 |
| Richard J. Destefane Revocable Living Trust | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2025 |
| TLG II LLP | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2025 |
| Washburn, Troy | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2025 |
| Washburn, Troy | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you learn about each resident's background and history, and how does that shape their care?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you manage residents' personal funds, and how often do families receive an accounting?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Living Center, the | 1.9 mi | Marshall, MO | ★★★☆☆ | 3/5 | |
| Apple Ridge Care Center | 19.2 mi | Waverly, MO | ★☆☆☆☆ | 2/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 265508.