Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0567

Level of harm – Potential for minimal harm

Residents Affected – Many

Honor the resident’s right to manage his or her financial affairs.

Based on interview and record review, the facility failed to ensure each resident was
afforded the right to manage his or her financial affairs when the facility failed to have
consent to act as fiduciary of the funds for two additional residents (Resident #10 and
#18) and failed to allow two residents (Resident #15 and #3) of 12 sampled residents and
seven additional residents (Resident #18, #10, #9, #23, #8, #17, and #6) access to their
personal funds on an ongoing basis. The facility managed funds for nine residents. The
facility census was 31.
1. Review of the facility policy Final Conveyance of Resident Funds and Credit Balances,
dated 2001 and last revised 4/14, showed the following:
The facility maintains a system that assures a full, complete, and separate accounting,
according to generally accepted accounting principles, for each resident’s funds entrusted
to the facility on the resident’s behalf. The systems precludes and commingling of
resident funds with facility funds unless instruction has been obtained and authorized by
the resident/responsible party.
Policy Interpretation and Implementation
5. Guidelines for the conveyance of resident funds and credit balances
a. Resident funds over fifty dollars must be deposited in a resident trust fund interest
bearing account which is separate from the facility’s bank account;
g. Funds less than fifty dollars not on deposit in the resident’s trust fund account are
deposited into the resident petty cash fund managed by the facility on behalf of the
residents.
2. Review of the facility Admission Agreement revised 2019 showed the facility agreed to
safeguard, manage and account for resident’s personal funds to the extent required by
applicable federal and state regulations unless the resident indicated on Attachment 2
(Personal Funds) that they did not wish the facility to provide this service;
-Attachment 2 (Personal Funds) showed in part: The facility offered the service of holding
and managing residents’ personal funds. The facility would provide the service of holding
and managing personal funds only if the resident or the resident’s legally authorized
representative signed this Attachment, giving the facility written authorization to
perform the service.
3. Review of Resident #10’s Resident Account Authorization form signed and dated 12/15/15
showed authorization declined. The resident did not authorize the facility permission to
take care of his/her personal spending money.
Review of the facility Trust Fund Statement Register dated (MONTH) 2019 showed the
resident’s balance was $67.90.
During interview the resident said only the administrator was able to withdraw cash from
his/her account at the bank. He/she told the Business Office Manager (BOM) how much cash
he/she wanted, the BOM told the administrator and the administrator went to the bank to
withdraw the cash for him/her. Sometimes he/she received the cash on the same day but
usually it took a while to get cash. He/she was never able to obtain cash on weekends or
holidays.
4. Review of Resident #18’s Resident Account Authorization form signed and dated 9/21/16
showed authorization declined. The resident did not authorize the facility permission to
take care of his/her personal spending money.
Review of the facility Trust Fund Statement Register dated (MONTH) 2019 showed the
resident’s balance was $7.30.
During interview the resident said he/she only had a few dollars in the trust fund.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0567

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 1)
His/her sister managed most of his/her money. He/she did not know how to get cash from the
trust fund. He/she had not asked the BOM for any cash yet.
5. Review of the facility Trust Fund Statement Register dated (MONTH) 2109 showed the
following residents with fund balances:
-Resident #15: $50.48;
-Resident #3: $1.00;
-Resident #9: $261.40;
-Resident #23: $30.09;
-Resident #8: $665.75;
-Resident #17: $547.48;
-Resident #6: $40.00.
6. During interview Resident #15 said it was hard to get cash from his/her account for
anything. It usually took five days to obtain cash from the account. He/she felt like
he/she was begging for his/her own money.
During interview on 1/17/19 at 11:30 A.M. the BOM said he/she told the administrator in
writing when a resident asked for cash from their Trust Fund Account. The administrator
was the only person who could withdraw funds from the resident Trust Fund Account. The
administrator went to the bank, obtained the cash, returned to the facility and gave
him/her the cash and the receipt. He/she then gave the cash to the resident and the
resident signed a receipt for the cash. The process was usually completed the same day or
within 24 hours. If the resident requested funds on the weekends or holidays, no funds
were available. If the administrator was away from the facility, no funds were available.
The facility did not keep petty cash at the facility.
During interview on 1/18/19 at 6:10 P.M. the administrator said the following:
-Staff should obtain signed permission forms from residents or their legal representatives
before depositing resident funds in the trust fund account;
-The BOM requested a resident’s funds from the trust fund and she obtained the requested
cash from the bank. She went to the bank as soon as she was aware of the resident’s
request for funds within the same day unless she was unavailable;
-She was the only person on the account and only person allowed to withdrawal funds from
the trust fund account at the bank. The facility did not keep petty cash on hand;
-She obtained the requested cash at the bank, gave the cash to the BOM who dispersed the
funds to the resident.

F 0568

Level of harm – Potential for minimal harm

Residents Affected – Many

Properly hold, secure, and manage each resident’s personal money which is deposited
with the nursing home.

Based on interview and record review, the facility failed to maintain a system to ensure
the resident petty cash fund was reconciled for an accurate accounting of all monies held
in the resident trust fund account. The facility also failed to provide quarterly
statements in writing for two residents (Resident #3 and #15) of 12 sampled residents and
for seven additional residents (Resident #18, #10, #9, #23, #8, #17, and #6). The facility
managed funds for nine residents. The facility census was 31.
1. Review of the facility policy Final Conveyance of Resident Funds and Credit Balances,
dated 2001 and last revised 4/14, showed the following in part:
The facility maintains a system that assures a full, complete, and separate accounting,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0568

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 2)
according to generally accepted accounting principles, for each resident’s funds entrusted
to the facility on the resident’s behalf. The systems precludes and commingling of
resident funds with facility funds unless instruction has been obtained and authorized by
the resident/responsible party.
Policy Interpretation and Implementation
1. The individual financial records are available through quarterly statements and upon
request by the resident/responsible party;
5 c. All written accounts of resident funds shall be reconciled monthly and written
statements showing the current balance and all transactions, shall be given to the
resident, hi/her designee, guardian, and/or conservator on a quarterly basis and upon
request by the resident/responsible party.
2. Review of the facility’s monthly receipts folders labeled (MONTH) (YEAR) through
(MONTH) (YEAR) provided by the Business Office Manager (BOM) showed an unsealed bank
envelope contained $2.07 in the (MONTH) (YEAR) receipts folder. A receipt for the purchase
of cigarettes with cash returned in the amount of $2.07 was in the envelope. Resident #8’s
name was written on the outside of the bank envelope.
During interview on 1/17/19 at 11:30 A.M. the Business Office Manager said the following:
-He/she could not find resident receipts folders for (MONTH) and (MONTH) (YEAR);
-He/she thought the $2.07 in the (MONTH) (YEAR) resident receipt folder belonged to
Resident #8 and was the change from purchase of cigarettes for the resident. Resident #8
had funds in the resident trust fund and the $2.07 should have gone to the resident or
deposited in the trust fund account. The $2.07 should not be in a bank envelope in the BOM
files;
-He/she started working as the facility BOM in (MONTH) (YEAR);
-In (MONTH) (YEAR) he/she found three lock boxes and bank deposit bags containing cash and
change in the BOM’s office some of which had notes attached and some were loose in the
bags and lock boxes. The cash and change was petty cash;
-The cash and change was counted and totaled $287.21;
-$238.00 was deposited in the operating account as money received from families and
visitors for meals purchased at the facility and for stamps purchased from the facility;
-$49.21 was deposited in the operating account as money received from residents for
purchases made by the facility for residents. He/she was unsure what the purchases were
and did not have a receipt for those purchases;
-The facility had petty cash from (MONTH) (YEAR) through (MONTH) (YEAR). No accounting of
the petty cash was documented or reconciled;
-In (MONTH) (YEAR), the facility no longer had petty cash.
Review of the facility’s monthly bank statements and resident trust fund records for
(MONTH) (YEAR) through (MONTH) (YEAR) showed from (MONTH) (YEAR) through (MONTH) (YEAR) no
reconciliation of petty cash or the amount of petty cash kept at the facility.
During interview on 1/18/19 at 8:50 A.M. Resident #15 said he/she did not know the balance
of his/her trust fund account. The facility did not send out quarterly statements.
During interview on 1/18/19 at 9:15 A.M. Resident #10 said the facility did not send
him/her a trust fund account statement. He/she asked the BOM for the current amount in
his/her account. The BOM manager wrote the account balance on a piece of paper for
him/her.
During interview on 01/17/19 at 4:35 P.M. the Business Office Manager said no petty cash
reconciliation was found from (MONTH) (YEAR) through (MONTH) (YEAR). The facility did not
send out quarterly statements to residents or resident representatives with funds in the
facility trust fund.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0568

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 3)
During interview on 1/18/19 at 6:10 P.M. the administrator said the BOM should send out
quarterly statements to all residents or resident representatives with funds in the
facility trust fund account. A resident’s cash funds should not be in a bank envelope in
the BOM office since (MONTH) (YEAR). Any change from a purchase should be returned to the
resident or deposited in the resident’s trust fund account. The facility no longer kept
petty cash. Previous petty cash should be reconciled on the facility monthly
reconciliation form.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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.

Based on observation and interview the facility failed to provide a clean and comfortable
environment and ensure the three common bathroom/shower rooms were clean and in good
repair. The facility census was 31.
1. Review of the facility policy Cleaning and Disinfection of Environmental Surfaces, last
revised 6/09 showed the following:
Environmental surfaces will be cleaned and disinfected according to the current Centers
for Disease Control (CDC) recommendations for disinfection of healthcare facilities and
the Occupational Safety and Health Administration (OSHA) Blood-borne Pathogens Standard;
1. The following categories are used to distinguish the levels of
sterilization/disinfection necessary for items used in resident care and those in the
resident’s environment:
c. Non-critical items are those that come in contact with intact skin but not mucous
membranes;
-Non-critical environmental surfaces include bed rails, some food utensils, bedside
tables, furniture and floors;
-Non-critical surfaces will be disinfected with an EPA-registered intermediate or
low-level hospital disinfectant according to the label’s safety precautions and use
directions;
-Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis (e.g.,
daily, three times per week) and when surfaces are visibly soiled.
2. Observation of Cash Hall common bathroom/shower room showed the following:
-On 1/17/19 at 6:35 A.M. the entire bathtub base was covered with dried dirt, hair and
debris. The bathtub drain was plugged with hair and debris. All corners of the baseboard
were soiled with dirt and debris. An approximate three inch square hole was present in the
corner baseboard behind the door. The toilet base was brown around the base. The window
located directly beside the toilet contained a window blind with five broken slats. The
facility back parking lot and trash receptacles were visible through the broken window
blind slats. The sink faucet handles were soiled and rusted across the top;
-On 1/18/19 at 8:40 A.M. the entire bathtub base was covered with dried dirt, hair and
debris. The bathtub drain was plugged with hair and debris. All corners of the baseboard
were soiled with dirt and debris. An approximate three inch square hole was present in the
corner baseboard behind the door. The toilet base was brown around the base. The window
located directly beside the toilet contained a window blind with five broken slats. The
facility back parking lot and trash receptacles were visible through the broken window
blind slats. The sink faucet handles were soiled and rusted across the top. The toilet

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
paper holder was broken and the toilet paper roll was propped up on the grab bar next to
the toilet. A clear plastic bag of feces soiled clothing lay on top of the dirty linen
cart parked next to the sink area and visible from the door.
3. Observation of the Presley Hall common bathroom/shower room showed the following:
-On 1/17/19 at 6:55 A.M. two sink areas, one on each side of a floor to ceiling cabinet.
One sink area counter was stacked with two large boxes labeled with a resident’s name and
contained incontinence briefs. Under the same sink on the floor were two additional boxes
of incontinence briefs labeled with the same resident’s name. A stack of wheelchair
cushions and other medical equipment sat on the floor under the same sink;
-On 1/18/19 at 8:55 A.M. two sink areas, one on each side of a floor to ceiling cabinet.
One sink area counter was stacked with two large boxes labeled with a resident’s name and
contained incontinence briefs. Under the same sink on the floor were two additional boxes
of incontinence briefs labeled with the same resident’s name. A stack of wheelchair
cushions and other medical equipment sat on the floor under the same sink. A mechanical
lift (used for resident care and transfers), was parked in front of the sink area and was
soiled with brown dirt and grime across the lifting bar (area where the resident’s lift
pad was attached to the mechanical lift), and across the base metal support legs.
4. Observation of the Twitty Hall common bathroom/shower room showed the following:
-On 1/17/19 at 8:00 A.M. dirt and debris around the baseboard corner near the sink area.
Shower stall base board edges were soiled with dirt and debris, a black substance was
present on the bottom edge of the wall under the faucet area, a broken sliver of bar soap
was present in the shower stall drain with hair and debris and a soiled wound dressing lay
in the corner of the shower stall on the floor next to a gallon container of shower soap.
The shower chair seat contained a dark brown substance on the inside edge. The window
contained a window blind with two broken slats. The facility front entry way and resident
smoking area were visible through the broken window blind slats;
-On 1/18/19 at 8:35 A.M. dirt and debris around the baseboard corner near the sink area.
Shower stall base board edges soiled with dirt and debris, a black substance was present
on the bottom edge of the wall under the faucet area, the same broken sliver of bar soap
was present in the shower stall drain with hair and debris, the same soiled wound dressing
lay in the corner of the shower stall on the floor with a pile of dirt, hair and debris
next to a squeegee mop propped against the wall. The gallon container of shower soap sat
on the floor near a shower chair placed in the center of the shower stall covered with a
towel. The window contained a window blind with two broken slats. The facility front entry
way and residents smoking area were visible through the broken window blind slats. The tub
area and central walking area contained one large upright shower chair, two wheelchairs,
two bedside commodes and a wide shower chair.
5. During interview on 1/18/19 at 9:00 A.M. the Maintenance/Housekeeping Director said the
following:
– The housekeeping staff should clean the common bathroom/shower rooms daily;
-The Twitty Hall bathroom/shower room was not homelike and not clean. The baseboards were
rusty and soiled, the shower stall should not contain dirt, debris, or soiled wound
dressings on the floor. There was too much equipment stored in the Twitty Hall
bathroom/shower room. The blinds were broken and needed replaced to provide privacy;
-The Cash Hall bathroom/shower room bathtub contained dried dirty mop water where a staff
member emptied a mop bucket. Staff needed to clean the bathtub. The baseboards were soiled
with rust and needed cleaned. The window blinds were broken and needed replaced to provide
privacy;
-The Presley Hall was recently remodeled and meant for one resident at a time. No privacy
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
curtains were provided for the jetted tub area. Staff stored a resident’s boxes of
incontinence briefs on the sink counter and under the sink on the floor. He/she did not
know where else to store the resident’s supplies. The medical equipment stacked under the
sink blocked the use of the sink. There was another sink for resident use. The mechanical
lift was soiled and dirty. Staff needed to clean the lift.
During interview on 1/18/19 at 6:10 P.M. the administrator said housekeeping staff should
clean all three common bathroom/shower rooms daily. The facility should not have dirty
bathrooms, shower rooms, bathtubs and shower stalls. The shower stalls should not contain
soiled wound dressings. The shower rooms should not have broken blinds. Staff should not
store medical equipment in the common bathrooms/shower rooms and staff should not store a
resident’s boxes of incontinence briefs in the bathroom/shower room. She expected staff to
keep the common bathroom/shower rooms clean as well as the rest of the facility.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interview and record review, the facility failed to screen three new employees,
Cook B, Licensed Practical Nurse (LPN) C, and the Maintenance Director in a review of
eight newly hired employees to determine if any had a Federal indicator with the Nurse
Aide Registry that would prohibit employment at the facility. The facility census was 31.
1. Review of the facility policy Abuse Prevention Program, dated 2001 and last revised
8/06 showed the following:
-Our residents have the right to be free from abuse, neglect, misappropriation of resident
property, corporal punishment and involuntary seclusion;
-Our facility is committed to protecting our resident from abuse by anyone including, but
not necessarily limited to facility staff;
-Our facility conducts employee background checks and will not knowingly employ any
individual who has been convicted of abusing, neglecting or mistreating individuals.
2. Review of Cook B’s employee file showed the following:
-Hired on 9/27/18;
-No evidence the facility completed the Nurse Aide Registry check upon hire.
3. Review of LPN C’s employee file showed the following:
-Hired on 11/14/18;
-No evidence the facility completed the Nurse Aide Registry check upon hire.
4. Review of Maintenance Director’s employee file showed the following:
-Hired on 11/27/18;
-No evidence the facility completed the Nurse Aide Registry check upon hire.
During interview on 1/15/19 at 4:44 P.M. the Business Office Manager said the following:
-She was responsible for completing the background checks and screening on new employees
except the nursing staff;
-She was not aware she needed to complete the Nurse Aide Registry check on all new
employees. The Director of Nursing did nurse aide registry checks on new nursing
department staff only. She did not complete the Nurse Aide Registry check on any other
non-nursing new employees.
During interview on 1/18/19 at 6:10 P.M. the administrator said she expected the Business
Office Manager to complete the nurse aide registry checks on all new employees upon hire.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to report an allegation of
physical abuse regarding one resident (Resident #21) in a review of 12 sampled residents.
The facility failed to report to the State Agency within the required two hour time frame
an allegation a staff member slapped the resident. The facility census was 31.
1. Review of the facility policy Abuse Investigations, dated 2001 and last revised 4/2014,
showed the following:
-All reports of resident abuse, neglect and injuries of unknown source shall be promptly
and thoroughly investigated by the facility management.
-14. The Administrator will report alleged abuse or neglect to the state survey agency.
Immediate means as soon as possible. If the events that cause the allegation involve abuse
or result in serious bodily injury, it must be reported no later than 2 hours after the
allegation is made. If the events that cause the allegation do not involve abuse and do
not cause serious bodily injury, it must be reported within 24 hours after discovery of
the incident.
2. Review of Resident #21’s face sheet showed the following:
-admitted to the facility 12/5/18;
-[DIAGNOSES REDACTED].
Review of the resident’s admission Minimum Data Set (MDS) a federally mandated assessment
instrument, completed by facility staff, dated 12/17/18 showed the following:
-Cognitively intact;
-No evidence of an acute change in mental status from baseline;
-No hallucinations or delusions;
-No physical, verbal or other behavioral symptoms directed towards others;
-No rejection of care;
-Required limited assistance of one staff member with transfers, walking in room,
toileting and personal hygiene.
Review of the resident’s nurses’ notes dated 1/10/19 at 5:41 P.M. showed staff reported
this morning the resident reported that he/she was slapped in the face during the evening
shift last night by a staff member. Upon hearing this information a full investigation was
started, family and physician were notified. No injuries or bruising were noted on the
resident. A report was made to the State Agency appropriately. Staff would continue to
investigate and monitor the situation as needed.
During interview on 1/15/19 at 5:00 P.M Resident #21 said the following:
-About a month ago, a staff member came to his/her room, helped him/her to the bathroom
and jerked him/her around;
-Resident #21 called the staff member a [***] and slapped the staff member on the face;
-The staff member slapped him/her back on the face;
-Resident #21 told another worker about the incident. Resident #21 did not know when or
which staff member he/she told about the staff that slapped him/her;
-He/she did not know the staff member’s name who slapped him/her;
-Resident #21 said his/her face hurt for awhile after the staff member slapped him/her.
During interview on 1/16/19 at 12:20 P.M. CNA J said the following:
-He/she worked a double shift from 6:00 A.M. to 10:00 P.M. on 1/9/19;
-On 1/9/19 he/she went to supper break from 7:00 P.M. to 7:30 P.M. While he/she was

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
eating, Resident #21’s call light came on and CNA I answered the call light. CNA I came
back to the area where CNA J was eating in five to ten minutes and said don’t be surprised
if Resident #21 said I threw him/her into bed;
-CNA J came back to work at 6:00 A.M. on 1/10/19;
-The night shift staff said something happened with Resident #21. CNA K from night shift
told the day shift during rounds Resident #21 said a staff member slapped him/her;
-The night shift and day shift staff were talking about the incident during rounds at the
change of shift. The night shift charge nurse, LPN L, was aware of the incident. The day
shift nurse, LPN M, heard about the incident from LPN L during change of shift;
-CNA J should have told the charge nurse the previous evening about the situation with
Resident #21 and CNA I. It was his/her responsibility to report potential abusive
situations immediately.
During interview on 1/16/19 at 12:20 P.M. LPN M said the following:
-He/she worked the day shift from 6:00 A.M. to 2:00 P.M. on 1/10/19;
-He/she went to assess the resident at approximately 7:00 A.M. The resident said when
he/she went to bed last night a staff member was rough with him/her. The resident said
he/she called the staff member a [***] and slapped the staff member. The staff member
slapped him/her back and held the right side of his/her right face;
-The night shift nurse, LPN L, mentioned it to LPN M during report. LPN L said the
resident told him/her about it while passing the resident’s 5:30 A.M. medications;
-LPN M did not know if LPN L reported the allegation to anyone else. LPN L should have
called the DON.
During interview on 1/17/19 at 5:50 A.M. LPN L said the following:
-He/she was the night shift charge nurse on 1/9/19;
-CNA staff told LPN L on 1/10/19 at about 6:30 A.M. or 6:45 A.M. Resident #21 said a staff
member slapped him/her the evening before while getting ready for bed.
During interview on 1/18/19 at 7:00 P.M. the Director of Nursing said the following
-He/she was unaware the night shift staff knew of Resident # 21’s allegations a staff
member slapped him/her;
-The night shift staff should have reported the allegation to the DON immediately and an
investigation should have started immediately;
-Staff should have reported the allegation of abuse to the state agency within two hours;
-The facility did not report the allegation of abuse within two hours of knowing about the
allegation.

F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform residents or legal
representatives of their bed hold protocol at the time of transfer for one resident
(Resident #24) of 12 sampled residents and for one resident (Resident #30) of three closed
record reviews. The facility census was 31.
1. Review of the facility undated Discharge Policy showed the following:
-Our facility shall plan and prepare a resident for discharge or transfer. All discharge
and transfer information will be documented in the resident’s medical record;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 8)
-When a resident is scheduled for a transfer or discharge, the business office and/or
Social Services will notify Nursing Service of the transfer or discharge so that
appropriate procedures can be implemented.
2. Review of the facility’s Admission Agreement revised 2019 showed the following under
Bed Reservation section:
-All residents were notified upon admission of the Bed Hold Policy. Please review the
explanation and initial your request to identify how you would like your bed managed while
you are out of the facility on temporary/therapeutic leave or at the hospital;
-Three sections followed one each for Private Pay, Medicare and Medicaid payment source;
-The resident or responsible party was asked to choose if they requested the facility to
hold the resident’s bed or not while the resident was out of the facility on
temporary/therapeutic leave or at the hospital;
-If the resident or representative requested the resident’s bed not be reserved the
resident or representative could still request the bed be reserved but must do so in
writing within 24 hours of the resident’s departure from the facility.
3. Review of Resident #24’s Face Sheet showed admitted [DATE].
Review of the resident’s Nurses Notes showed the following:
-On 12/19/18 transferred to the hospital;
-On 12/20/18 readmitted to the facility.
Record review showed no documentation the resident was informed in writing of the
facility’s bed hold policy at the time of transfer on 12/19/18.
4. Review of Resident #30’s Face Sheet showed the following:
-admitted [DATE];
-discharge date [DATE] with return anticipated.
Review of the resident’s closed record showed on 12/12/18 the resident was taken to a
physician appointment and admitted to the hospital.
Record review showed no documentation the resident was informed in writing of the
facility’s bed hold policy at the time of transfer on 12/12/18 with return anticipated.
5. During interview on 1/15/19 at 3:20 P.M. the Social Services Designee said the
following:
-He/she reviewed the facility bed hold policy with residents and responsible parties at
the time of admission;
-He/she had not provided written bed hold policy information to residents or responsible
parties when the resident was transferred out of the facility;
-He/she needed to start sending out the bed hold policy letters at the time of a
resident’s transfer. He/she had the letters but had not sent any out yet.
During interview on 1/18/19 at 6:10 P.M. the administrator said staff should notify
residents and responsible parties in writing at the time of admission and again when
transferred out of the facility of the facility’s bed hold policy.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
held pressure to the lacrimal duct after instillation of eye drops for one resident
(Resident #11) in a review of 12 sampled residents and failed to ensure non-crushable

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
medications were not crushed during medication administration for one additional resident
(Resident #6). The facility census was 31.
1. Review of the facility policy Crushing Medications, dated 2001 and last revised 4/07
showed the following:
Policy Statement: Medications shall be crushed only when it is appropriate and safe to do
so, consistent with physician orders;
1.) The nursing staff and/or Consultant Pharmacist shall notify any practitioner who gives
an order to crush a drug that the manufacturer states should not be crushed (for example,
long-acting or [MEDICATION NAME] coated medications); The practitioner or Consultant
Pharmacist must identify an alternative or the practitioner must document (or provide the
nurses with a clinically pertinent reason to document) why crushing the medication will
not adversely affect the resident.
2. Review of the facility policy Instillation of Eye Drops, dated 2001 and last revised
1/14 showed the following:Purpose: The purpose of this procedure is to provide guidelines
for instillation of eye drops to treat medical conditions, eye infections and dry eyes;
Preparation: Review the resident’s care plan to assess for any special needs of the
resident; Assemble the equipment and supplies as needed;
Steps in the procedure: Place the equipment on the bedside stand or over-bed table.
Arrange the supplies so they can be easily reached; Wash and dry our hands thoroughly; Put
on gloves; If the resident is sitting up, tilt his/her head backward slightly; If the
resident is bedfast, position the resident’s head on the pillow and tilt the head backward
slightly; Draw medication into the dropper; Gently pull the lower eyelid down and instruct
the resident to look up; Drop the medication into the mid lower eyelid (fornix). (Note: Do
not touch the eye or eyelid with the dropper.) Recap the medication bottle; instruct the
resident to slowly close his/her eyelid to allow for even distribution of the drops.
Instruct the resident not to blink or squeeze the eyelids shut, which forces the
medication out.
3. Review of [MEDICATION NAME] ocular lubricant (used to relieve burning, irritation and
discomfort from dry eyes) manufacturer’s guidelines showed the following:
To apply the eye drops:
Tilt head, create pocket by pulling the lower eyelid down, instill the eye drop, close
your eyes for two or three minutes with your head tipped down, without blinking or
squinting. Gently press your finger to the inside corner of the eye for about one minute
to keep the liquid from draining into the tear duct.
4. Review of www.drugs.com showed the following:
-[MEDICATION NAME]-[MEDICATION NAME] (used to treat [MEDICAL CONDITION]) (disorder of the
central nervous system that affects movement, often including tremors) extended release
(ER): Do not crush, chew, break, or open a [MEDICATION NAME] and [MEDICATION NAME]
capsule. Swallow it whole. The tablet is sometimes broken in half to give the correct
dose. Always swallow a whole or half tablet without chewing or crushing;
-Potassium chloride (CL) ER (supplement): do not crush, chew, break, or suck on an
extended-release tablet or capsule. Swallow the pill whole. Breaking or crushing the pill
may cause too much of the drug to be released at one time.
5. Review of Resident #6’s Physician Order Sheet (POS) dated 1/19, showed the following:
-[DIAGNOSES REDACTED].
-May crush medications unless contraindicated;
-Potassium Cl ER 20 Meq (milliequivalants) PO (by mouth) three times daily (1/31/18);
-[MEDICATION NAME]-[MEDICATION NAME] ER ,[DATE] milligrams one PO three times daily;
-Pureed diet with nectar thickened liquids.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
Observation on 1/15/19 at 12:35 A.M. showed the following:-The resident sat in his/her
wheelchair in the dining room;
-Licensed Practical Nurse (LPN) M retrieved and dispensed the resident’s medications,
crushed the Potassium CL ER and the [MEDICATION NAME]-[MEDICATION NAME] ER, placed them in
applesauce and administered the crushed medications to the resident.
6. Review of Resident # 11’s POS, dated 1/19 showed the following:-[DIAGNOSES REDACTED].
-[MEDICATION NAME] 0.3-0.4% eye drops-one drop both eyes three times daily.
Observation on 1/15/19 at 12:35 P.M., showed LPN M administered the resident’s eye drops
as the resident sat upright in his/her wheelchair. LPN M administered one drop of
[MEDICATION NAME] eye drops into each of the resident’s eyes. Staff handed the resident a
Kleenex but did not hold pressure to the lacrimal duct after administration and did not
instruct the resident to do so.
During interview on 1/30/19 at 10:20 A.M. LPN M said the following:
-Medications that should not be crushed are potassium and extended release medications;
-Pressure should be applied to the lacrimal duct after instillation of [MEDICATION NAME]
eye drops.
During interview on 1/18/19 at 5:50 P.M. the Director Of Nursing said the following:
-He/she would not expect [MEDICATION NAME]-[MEDICATION NAME] ER or potassium to be
crushed;
-He/she would expect staff to administer eye drops according to the manufacturer’s
guidelines, holding pressure to the lacrimal duct if instructed to do so.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide oral
care for two residents (Resident #4 and #19) in a review of 12 sampled residents. The
facility census was 31.
1. Review of the facility policy Mouth Care, dated 2001 and revised 10/10 showed:
The purpose of this procedure are to keep the resident’s lips and oral tissues moist, to
cleanse and freshen the resident’s mouth, and to prevent infections of the mouth.
1. Review the resident’s care plan to assess for any special needs of the resident.
2. Assemble the equipment.
Equipment and supplies: toothbrush, toothpaste, emesis basin, towel, fresh water,
mouthwash (if permitted), disposable cup, straw, tongue depressor, applicators or gauze
sponges, lubricants (petroleum jelly, etc.) and personal protective equipment (gown,
gloves, mask, etc., as needed).
Steps in the Procedure:
-Place the equipment on the bedside stand or over-bed table. Arrange the supplies so they
can be easily reached;
-Wash and dry your hands thoroughly; Allow the resident who is able to provide his/her own
mouth care to do so; Gently turn the resident’s head toward you; Put on gloves; Spread the
towel under the resident’s chin and across the pillow to protect he resident’s clothing
and/or bed covers; Position the emesis basin on the towel under the resident’s chin;
Gently open the resident’s mouth; Hold the tongue with the tongue depressor; With the free
hand, moisten the applicators with the mouthwash solution; Insert the applicator into the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
resident’s mouth; Thoroughly wipe the roof of the resident’s mouth, inside the cheeks, the
tongue, and the teeth with the applicator; Place all used applicators into the emesis
basin; Rinse the resident’s mouth by using clear (fresh) water on the applicators; Dry the
resident’s face and chin area, Remove the towel; Moisten the inside of the resident’s
mouth, tongue and lips. Use a prepared swab or a water soluble lubricant; Remove gloves
and discard into designated container. Wash your hands; Clean your equipment and return to
designated storage area; Discard disposable equipment and supplies in designated
containers; Discard towels in soiled laundry hamper; Reposition the bed covers and make
the resident comfortable; Place call light within easy reach of the resident; Wash and dry
your hands thoroughly.
2. Review of the Nurse Assistant in a Long Term Care Facility manual, Revision (MONTH)
2001, showed the following:
-Purposes of oral hygiene (mouth care): A clean mouth and properly functioning teeth are
essential for physical and mental well-being of the resident, prevent infections in mouth,
remove food particles and plaque, stimulate circulation of gums, eliminate bad taste in
mouth, thus food is more appetizing;
-Give oral care before breakfast, after meals, and also at bedtime;
-Specific observations to make: tooth decay, any loose or broken teeth, red or swollen
gums, sores or white patches in the mouth or on the tongue, changes in eating habits, and
poorly fitting dentures;
-A clean mouth is very important to the physical and mental well-being of the resident.
Oral care can prevent infections, the buildup of plaque, and bad breath. It can even
influence the resident’s appetite. Remember to observe the resident during oral care to
identify potential problems.
3. Review of Resident #19’s significant change Minimum Data Set (MDS) a federally mandated
assessment instrument, completed by facility staff, dated 12/10/18 showed the following:
-[DIAGNOSES REDACTED].
-Short and long term memory problem;
-Required total assistance of one staff member with eating and personal hygiene.
Review of the resident’s care plan dated 12/11/2018 showed the resident had his/her own
teeth and required assistance with brushing teeth. Staff should assist the resident with
brushing his/her teeth after meals, monitor for completeness and assist as needed. Staff
should monitor for any signs of discomfort, sores or irritation in and around mouth and
report to charge nurse.
Observation on 1/17/19 at 6:55 A.M. showed the following:
-Certified Nurse Assistant (CNA) D and CNA E provided the resident incontinence care,
dressed the resident in a clean incontinence brief, pants and shirt and transferred the
resident from the bed to a wheelchair;
-The resident’s lips were dry and peeling;
-His/her mouth was dry, tongue coated with white substance and teeth with white debris;
-CNA E brushed the resident’s hair and took the resident to the dining room for breakfast;

-CNA D and CNA E did not provide oral care.
During interview on 1/17/19 at 7:18 A.M. CNA E said there was no reason oral care was not
provided. Oral care should be provided before breakfast, they were running late.
Observations on 1/17/19 showed the following:
-At 7:45 A.M. the resident drank four ounces of juice with a straw followed by breakfast
including milk and water;
-At 9:30 A.M. the resident sat in his/her room. The resident’s mouth remained with dry,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
peeling lips. His/her teeth with debris and food particles.
During interview on 1/17/19 at 11:55 A.M. the resident’s family member said the following:
-He/she visited the resident almost every day and came to the facility early in the
mornings. He/she assisted the resident with almost every meal;
-The resident drank a lot of fluids at meal times to assist with swallowing foods;
-Staff did not brush the resident’s teeth very often;
-Staff did not brush the resident’s teeth this morning or following breakfast.
Observation on 1/17/19 at 11:55 A.M. showed the resident’s teeth with debris and a white
coating.
4. Review Resident #4’s care plan dated 8/7/18, showed the following:
-Problem: Blind and needs guidance with cares; Goal: Resident will be able to navigate and
assist with Activities of Daily Living (ADLs) at his/her optimal ability with the help of
staff; Approaches: Provide assistance with ADLs;
-Problem: Edentulous; Goal: Oral care daily; Approaches: Assist resident with maintaining
good oral hygiene care, hand him/her his/her toothbrush and have him/her brush his/her
teeth at the wheelchair level in front of the sink.
Review of the resident’s quarterly MDS, dated [DATE] showed the following:
-Severely impaired vision: no vision or sees only light, colors or shapes, eyes do not
appear to follow objects;
-Extensive assist of one for personal hygiene:
-No impairment of upper extremities.
Review of the resident’s POS dated 1/19 showed the following:
-[DIAGNOSES REDACTED].
-Fluid restriction of 2000 milliliters/24 hours.
Observation on 1/17/19 at 7:32 A.M., showed the following:
-The resident lay on the bed;
-CNA D and CNA E entered the room, checked the resident for incontinence, dressed the
resident and transferred him/her to the wheelchair;
-Staff assisted the resident to the dining room;
-Staff did not offer oral care to the resident.
During interview on 1/24/19 at 11:09 A.M., CNA D said that oral care should be offered
when residents rise in the morning, after meals and before bed.
During interview on 1/24/19 at 11:38 A.M., CNA E said that oral care should be offered
before and after meals but he/she had not completed.
5. During interview on 1/181/9 at 3:00 P.M. the Director of Nursing said the following:
-Staff should wash resident’s hands, face, brush teeth, provide oral care, and brush hair
in the mornings before breakfast;
-Staff should brush residents’ teeth after meals, after sleeping or naps and before bed
every day;
-Staff saying not enough time was not a good reason for not providing the residents
morning cares and brushing residents’ teeth.

F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide basic life support, including CPR, prior to the arrival of emergency medical
personnel , subject to physician orders and the resident’s advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the medical record

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
accurately and consistently indicated resident’s code status for three residents (Resident
#4, #7 and #15) in a review of 12 sampled residents. The facility census was 31.
1. Review of the facility policy Do Not Resuscitate Order and Notification, last revised
,[DATE] showed the following:
-Policy Statement: Our facility will not use cardiopulmonary resuscitation and related
emergency measures to maintain life functions on a resident when there is a Do Not
Resuscitate Order in effect. Our staff will be able to easily identify a resident code
status to provide care as ordered;
1. Do not resuscitate orders must be signed by the resident’s Attending Physician on the
physician’s order maintained in the resident’s record;
8. Resident code status is entered into the computer at time of admission. The Code Status
is entered on the face sheet and the Care Guide ADL. These two points of entry allow the
staff to quickly access a resident’s Code Status anywhere in the facility by viewing the
Kiosk (smart charting), Order Administration (MAR) or Face sheet.
2. Review of Resident #4’s chart showed the front had a sticker which read Full Code.
Review of the resident’s care plan dated [DATE] showed the resident wanted to be a Do Not
Resuscitate (DNR).
Review of the resident’s face sheet showed the following:
-Re-admission of [DATE];
-Full Code.
Review of the resident’s Physician Order Sheer dated ,[DATE], showed the resident had an
order for [REDACTED].
Review of the resident’s emergency health care directive (purple sheet) showed the
following:-Resident was a DNR;
-The resident representative signed and dated the request for DNR on [DATE];
-The resident’s physician signed and dated the request for DNR on [DATE].
3. Review of Resident #7’s emergency health care directive (purple sheet) located in the
front of the resident’s medical record showed the following:
-The resident signed and dated the request for Do Not Resuscitate on [DATE];
-The resident’s physician signed the request for Do Not Resuscitate on [DATE] ;
-The resident signed and revoked Do Not Resuscitate and requested a full code status on
[DATE].
Review of the resident’s face sheet showed the following:
-admitted [DATE];
-Do Not Resuscitate.
Review of the resident’s admission MDS dated [DATE] showed the following:
-Cognitively intact;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan dated [DATE] showed the resident was a full code.
Review of the resident’s medical record front hard cover showed a sign identifying the
resident was a full code.
Review of the resident’s Physicians Order Sheet showed the resident was a full code.
During interview on [DATE] at 3:00 P.M. the Director of Nursing said the resident’s code
status documentation was mixed up. The purple emergency health care directive was the
rule. The resident had revoked the Do Not Resuscitate and was a Full Code. Staff would not
notice the revocation on the form in the case of an emergency and would not provide CPR
and a full code. The purple form should be removed from the resident’s chart since the
resident desired Full Code status. The resident’s face sheet was filled out incorrectly.
4. Review of Resident #15’s face sheet showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-admission date of [DATE];
-Full Code.
Review of the resident’s hard chart showed the front had a sticker which read DNR.
Review of the resident’s emergency healthcare directive (purple sheet) located in the
front of the resident’s chart showed:-Resident was a DNR;
-The resident’s Durable Power of Attorney signed and dated the request for DNR on [DATE];
-The resident’s physician signed and dated the request for DNR on [DATE].
Review of the resident’s care plan dated [DATE] showed the resident’s annual review of
code status for the resident was a DNR.
Review of the resident’s POS, dated ,[DATE] showed the resident had an order for
[REDACTED].>5. During interview on [DATE] at 10:50 A.M. Certified Nurse Aide (CNA) D
said he/she did not know if a resident was a Full Code or a Do Not Resuscitate. He/she did
not know where to find the resident’s code status information. If he/she found a resident
unresponsive he/she would pull the resident’s call light and call for help.
During interview on [DATE] at 2:00 P.M. CNA H said if he/she found a resident unresponsive
he/she would call for help. He/she would check the resident’s care plan for their code
status.
During interview on [DATE] at 11:05 A.M., Licensed Practical Nurse (LPN) M said the
following:
-There was a message board on the computer screen which had a list of full code residents
and if a resident was not listed, they were a DNR;
-The front of the charts also had the code status listed;
-The Director of Nurses (DON) was responsible for updating the message board.
During interview on [DATE] at 3:10 P.M. the DON said the following:
-The emergency health care directive (purple sheet) located in the front of the resident’s
medical record was the rule. If the resident had a signed purple sheet the resident was a
Do Not Resuscitate;
-If the resident did not have a signed purple sheet in the front of their chart, they were
a full code;
-The front hard cover of the chart, the face sheet, the physician’s order sheet and the
emergency health care directive (purple sheet) should all match;
-If a resident’s code status changed, all documents should change to indicate the correct
wishes of the resident;
-All staff should know the residents’ code status and where to locate each resident’s code
status;
-The licensed nurses had a message board on the front screen of electronic medical record
system. The message board listed all full code residents. If the resident’s name was not
on the message board, they were a Do Not Resuscitate;
-He/she was responsible for updating the resident’s POS, the Social Service Director was
responsible for updating the face sheet and the MDS Coordinator was responsible for
updating the hard chart.
During interview on [DATE] at 6:10 P.M. the administrator said staff should know every
residents’ code status and know what to do in the event a resident was unresponsive. Each
resident’s facesheet, front of the chart, physician order sheet and emergency health care
directive (purple sheet) should all match with the same code status information.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to prepare and
serve pureed dinner roll for lunch on 1/15/19 and pureed garlic bread for supper on
1/15/19 to residents on a pureed diet. The facility census was 31.
1. Review of the facility policy, Pureed Food Preparation, dated 2011, showed the
following procedure:
-Pureed foods will be prepared using standardized recipes to ensure quality, flavor,
palatability and maximum nutritive value;
-All of the pureed food must be used in order to deliver the correct nutrient density to
each resident;
-Staff will be in-serviced on proper preparation of pureed foods.
2. Record review of the facility’s Consultant Dietician Report, dated 12/28/18, showed the
following summary of recommendations:
-Noted pureed food not made per recipe. Sausage, sauerkraut, bun was to be pureed together
and served with a #6 scoop. Only the meat was pureed and served with a #8 scoop;
-Registered Dietician (RD) questioned the cook about both concerns. The cook appeared to
not know what the recipe said. A similar incident happened last RD visit. RD met with the
cook after lunch and further explained spreadsheets and recipes;
-Staff may benefit from in-service on how to read spreadsheets and recipe compliance;
-This is an easy target for surveyors to tag dietary;
-RD is available to provide an in-service if requested for (MONTH) visit.
3. Review of the facility’s Physician Orders List, dated 1/15/19, showed three residents
had an order for [REDACTED].>4. Review of the facility diet spreadsheet (Fall/Winter
(YEAR)-2019, Week 4, Day 24) for lunch on 1/15/19 showed residents on a physician-ordered
pureed diet were to receive a #20 scoop of pureed dinner roll.
Review of the facility recipe book showed no recipe for pureed dinner roll for Week 4, Day
24.
Observation on 1/15/19 at 12:41 P.M. showed the nutrition services director plating food
for the lunch meal service. No pureed dinner roll was visible on the steam table or
anywhere in the tray assembly area.
Observation on 1/15/19 at 1:34 P.M. showed the meal service was completed. Staff did not
serve pureed dinner rolls to three residents on a pureed diet.
5. Review of the facility diet spreadsheet (Fall/Winter (YEAR)-2019, Week 4, Day 24) for
supper on 1/15/19 showed residents on a physician-ordered pureed diet were to receive a
#20 scoop of pureed garlic bread.
Review of the recipe for pureed garlic bread, showed the following directions:
-Place garlic bread in a washed and sanitized food processor;
-Add melted margarine;
-Gradually add milk, as needed;
-Blend until smooth;
-Portion with a #20 dip.
Observation on 1/15/19 at 5:45 P.M. at the end of the supper meal service showed the three
residents on a pureed diet received pureed cheese tortellini, pureed carrots, and pureed
cranberry fluff. Staff did not prepare pureed garlic bread and serve to the three
residents on a pureed diet.
6. During an interview on 1/15/19 at 12:05 P.M., the nutrition services director said she
hadn’t received any training on how to prepare pureed food items.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
During an interview on 1/16/19 at 11:30 A.M., the nutrition services director said there
were no recipes for pureed bread in the recipe book or directions anywhere else that
indicated how pureed bread was to be prepared or served.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation, interview, and record review, the facility failed to serve food at a
safe and appetizing temperature. The facility census was 31.
1. Review of the facility policy, Monitoring Food Temperatures for Meal Service, dated
2011, showed food temperatures of hot foods at the point of service are preferred to be at
120 degrees F or greater to promote palatability for the resident.
2. During interview on 1/15/19 at 12:25 P.M., Resident #10 said the food was not always
served hot.
During the group interview on 1/16/19 at 3:10 P.M., Resident #128 said sometimes hot food
is cold when served.
3. Observation on 1/15/19 at 1:43 P.M. of the test tray provided by dietary staff after
the last resident was served, showed the following:
-Meatloaf with ketchup glaze was 115.3 degrees Fahrenheit (F);
-Ground meatloaf was 102 degrees F.
During an interview on 1/16/19 at 11:30 A.M., the nutrition services director said food
should be 135 degrees Fahrenheit at the end of the meal service.

F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure pureed
food was prepared properly to meet the needs of the residents with a physician’s order for
a pureed diet. The facility also failed to ensure gravy was prepared and served on top of
mechanical soft food items to residents on a mechanical soft diet according to the
spreadsheet menu. The facility census was 31.
1. Review of the facility policy, Pureed Food Preparation, dated 2011, showed the
following:
-Standardized recipes will be used to prepare all pureed foods;
-Pureed foods will be prepared using standardized recipes to ensure quality, flavor,
palatability and maximum nutritive value;
-Pureed foods will be the consistency of applesauce or smooth mashed potatoes.
2. Record review of the facility’s Consultant Dietician Report, dated 12/28/18, showed the
following summary of recommendations:
-Noted pureed food not made per recipe;
-Registered Dietician (RD) questioned the cook about this concern. The cook appeared not
to know what the recipe said. A similar incident happened last RD visit.
-Staff may benefit from in-service on how to read spreadsheets and recipe compliance.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
3. Review of the facility’s Physician Orders List, dated 1/15/19, showed three residents
had an order for [REDACTED].>Review of the facility diet spreadsheet (Fall/Winter
(YEAR)-2019, Week 4, Day 24) for lunch on 1/15/19 showed residents on a physician-ordered
pureed diet were to receive a #8 scoop of pureed baked potato with sour cream.
Review of the recipe for pureed baked potato with sour cream showed the following:
-Remove skin from baked potatoes and place in a food processor along with sour cream.
Blend until smooth. Add small amounts of hot milk as needed until desired consistency is
achieved;
-Top pureed foods with appropriate sauces or gravies, as needed to ensure adequate
moisture for safe consumption and enhance flavor.
Observation 1/15/19 between 12:58 P.M. and 1:06 P.M. during the meal service, showed the
three residents on a pureed diet received pureed baked potatoes. The pureed baked potatoes
appeared chunky with large pieces of potato skins throughout the mixture.
Observation on 1/15/19 at 1:43 P.M. of the pureed foods test tray, showed the pureed baked
potato was chunky with large pieces of potato skin throughout the mixture. The pureed
baked potato was extremely thick and paste-like and stuck to the spoon. The item was
difficult to swallow without chewing.
During an interview on 1/16/19 at 11:30 A.M., the nutrition services director said she
used a real baked potatoes in the pureed baked potato recipe. The whole baked potato,
including the potato skin, was cut up, and butter, milk and sour cream were added to the
mixture.
4. Review of the facility’s Physician Orders List, dated 1/15/19, showed six residents had
an order for [REDACTED].>Review of the facility diet spreadsheet (Fall/Winter
(YEAR)-2019, Week 4, Day 24) for lunch on 1/15/19 showed residents on a mechanical soft
diet were to receive gravy on top of the ground meatloaf.
Review of the recipe for ground meatloaf showed the following:
-Place portions of meatloaf in a food processor. Pulse/grind until meatloaf is finely
ground. Transfer to steamtable pan and add enough broth to keep meat moist;
-Serve ground meatloaf with a #8 dip. Top with 1 to 2 ounces of additional broth.
Observation on 1/15/19 between 12:41 P.M. and 1:34 P.M. during the meal service, showed
staff served all residents on a mechanical soft diet ground meatloaf without any gravy. No
gravy was prepared or served during the meal service.
Observation on 1/15/19 at 1:43 P.M. of the mechanical soft test tray, showed the ground
meatloaf served without gravy. No gravy was served on the sample test tray.
During an interview on 1/16/19 at 11:30 A.M., the nutrition services director said no
gravy was prepared or served with the mechanical soft items.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure food
items were labeled, dated, discarded when expired; failed to ensure food scoops were not
stored inside bulk bins; failed to ensure the can opener blade was free of an accumulation
of debris; failed to ensure staff utilized proper glove use during food preparation during
meal service; and failed to ensure pans were not stacked and stored wet. The facility
census was 31.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 18)
1. Record review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated
2011, showed discard food that has passed the expiration date.
2. Record review of the facility policy, Handling Leftover Foods, dated 2011, showed
refrigerated leftovers stored beyond 72 hours shall be discarded.
3. Observation on [DATE] at 3:00 P.M. of the reach-in cooler in the kitchen showed the
following:
-A tall clear round container labeled gravy for breakfast sausage made ,[DATE];
-A tall white round container labeled turkey gravy dated ,[DATE];
-A tall white round container labeled carrots dated ,[DATE];
-A tall white round container labeled cinnamon apples dated [DATE];
-A tall white round container labeled carmel sauce dated ,[DATE];
-A tall round container labeled applesauce dated ,[DATE];
-A tall round container labeled tomato sauce dated ,[DATE];
-A tall container labeled sauerkraut dated ,[DATE].
-A tall clear container was not labeled or dated and contained sliced peaches.
Observation on [DATE] at 3:15 P.M. of the refrigerator labeled fridge#3 in the service
hallway behind the kitchen showed the following:
-A partial bag of iceberg lettuce in the door was not dated and had watery brown lettuce
and brown liquid in the bottom corners of the bag;
-A vacuum-sealed bag, labeled romaine lettuce had a manufacturer’s use by date of [DATE]
and contained brown lettuce and brownish liquid in the bag.
Observation on [DATE] at 3:45 P.M., showed Dietary Staff A retrieved the bag of romaine
lettuce out of the refrigerator in the service hall and used the lettuce to make the
tossed salad for the evening meal. The bag showed the lettuce expired on [DATE]. The salad
was to be used for residents that received regular and low-concentrated sweet diets.
During an interview on [DATE] at 11:30 A.M., the nutrition services director said food
items should be labeled and dated and were good for three days. After three days, staff
should discard the item. Staff should follow manufacturer’s use by dates if applicable.
Staff should use items or discard them by the expiration date. All cooks were responsible
for checking the refrigerators and cleaning them out every other day.
4. Observation on [DATE] at 3:20 P.M. and on [DATE] at 8:10 A.M. showed a black measuring
cup stored inside a bulk storage bin of flour in the dry storage room. The measuring cup
lay directly on top of the flour.
Observation on [DATE] at 3:30 P.M. and on [DATE] at 8:10 A.M. showed a measuring scoop
stored inside a bulk storage container of sugar, located under a metal preparation counter
in the kitchen. The measuring scoop lay directly on top of the sugar.
During an interview on [DATE] at 11:30 A.M., the nutrition services director said she was
not aware scoops were not supposed to be stored inside a bulk food storage container.
5. Record review of the facility policy, Cleaning Rotation, dated 2011, showed the can
opener should be cleaned after each use.
Observation on [DATE] at 3:31 P.M. showed dark and white colored debris on the blade of
the counter-mounted can opener. Dietary Staff A used the mounted can opener to open a
large can of spaghetti sauce. He/she did not clean the blade prior to utilizing the can
opener. After the can was opened, red spaghetti sauce was visible on the blade. Dietary
Staff A did not clean the blade after opening the can of spaghetti sauce.
Observation on [DATE] at 8:10 A.M. showed white-colored debris on the can opener blade.
During an interview on [DATE] at 11:30 A.M., the nutrition services director said staff
cleaned the can opener blade monthly by running it through the dish machine.
6. Record review of the facility policy, Guidelines for Dining Servers, Fundamentals to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 19)
Prevent Food Borne Illness, dated 2011, showed the following guidelines for Gloves Used
Correctly:
-Gloves are changed anytime they become soiled and between tasks;
-Gloves are treated like a food contact surface;
-Gloves are used anytime ready to eat foods must be touched by a hand and are changed if
they come in contact with an unclean surface, door or piece of equipment.
Observation on [DATE] between 12:41 P.M. and 1:34 P.M. during the lunch meal service
showed the nutrition services director placed food items on all residents’ meal plates.
She wore gloves and handled each resident’s diet card before preparing the resident’s
plate. After touching the diet cards, the nutrition services director placed a baked
potato on the resident’s plate, sliced it and used both of his/her hands to squeeze the
potato open. The nutrition services director proceeded with this process wearing the same
gloves through the entire meal service.
During an interview on [DATE] at 11:30 A.M., the nutrition services director said staff
should change gloves between clean and dirty processes.
7. Observation on [DATE] at 3:21 P.M. showed a stack of five large steam table pans stored
on a rack in the kitchen. When the pans were separated, there were water droplets in
between the pans.
Observation on [DATE] at 8:10 A.M. showed a stack of three small steam table pans stored
on the storage rack in the kitchen and had water droplets in between the pans when
separated.
During an interview on [DATE] at 11:30 A.M., the nutrition services director said dishware
should be air dried before staff stack them.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to follow
acceptable infection control practices and prevent cross-contamination during the
provision of cares and failed to ensure resident [MEDICATION NAME] testing was completed
as required. Staff failed to change gloves, wash hands and properly handle linens for one
resident (Resident #15) and failed to complete and document [MEDICATION NAME] testing for
one resident (Resident #4) in a review of 12 sampled residents and for one additional
resident (Resident #20). The facility census was 31.
1. Review of the facility policy Handwashing/Hand Hygiene dated 2001 and last revised 8/15
showed the following:
The facility considers hand hygiene the primary means to prevent the spread of infections.
All personnel shall be trained and regularly in-serviced on the importance of hand hygiene
in preventing the transmission of healthcare-associated infections; All personnel shall
follow the handwashing/hand hygiene procedures to help prevent the spread of infections to
other personnel, residents and visitors; Wash hands with soap (antimicrobial or
non-antimicrobial) and water for the following situations:
When hands are visibly soiled; after contact with a resident with infectious diarrhea
including, but not limited to infections caused by Norovirus, salmonella, Shigella and
[DIAGNOSES REDACTED]icile;
Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap
(antimicrobial or non-antimicrobial) and water for the following situations:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
Before and after direct contact with residents; Before preparing or handling medications;
Before and after handling and invasive device (e.g., urinary catheters, IV access sites);
Before handling clean or soiled dressings, gauze pads, etc .;
Before moving from a contaminated body site to a clean body site during resident care;
After contact with a resident’s intact skin; After contact with blood or bodily fluids;
After handling used dressings, contaminated equipment, etc.; After removing gloves. The
use of gloves does not replace hand washing/hand hygiene. Integration of glove use along
with routine hand hygiene is recognized as the best practice for preventing
healthcare-associated infections;
Applying and Removing Gloves-Perform hand hygiene before applying non-sterile gloves;
Perform hand hygiene after removing gloves.
2. Review of the facility Departmental Laundry and Linen policy, dated 2001 and last
revised 1/14 showed:
The purpose of this procedure is to provide a process for the safe and aseptic handling of
linen;
-Standard Precautions: Separate soiled and clean linens at all times, Wash hands after
handling soiled linen and before handling clean linen, Consider all soiled linen to be
potentially infectious and handle with standard precautions;
-Bagging and Handling Soiled Linens: All soiled linen must be placed directly into a
covered laundry hamper which can contain the moisture. Place any linen saturated with
blood or body fluids into a leak-resistant bag before placing it into the hamper. Handle
soiled linen as little as possible to prevent agitation.
3. Review of the facility policy [MEDICAL CONDITION] Screening-Administration and
Interpretation of [MEDICATION NAME] Skin Tests, dated 2001 and last revised 2/14 showed:
The facility will administer and interpret [MEDICATION NAME] skin tests (TST) in
accordance with recognized guidelines and pertinent regulations. After obtaining a
physician order, a qualified nurse or a healthcare practitioner will inject 0.1
milliliters (ml) (five [MEDICATION NAME] units) of purified protein derivative (PPD)
intradermally on the forearm. Individuals with less than ten millimeters (mm) of duration,
unless otherwise indicated, will receive a booster of 0.1 ml of PPD one to two weeks after
the initial TST. A qualified nurse or healthcare practitioner will interpret the TST
forty-eight to seventy-two hours after administration. All test results must be read in
mm.
4 . Review of the Infection Control Guidelines for Long Term Care Facilities, (MONTH) 2005
edition showed:
-Place all soiled linens in laundry bags provided at the point of use;
-Avoid contact with your uniform/clothing and surrounding patient care equipment;
-Do not shake or place linen directly on the floor;
-For linens lightly to moderately moist, fold and/or roll in such a way as to contain the
moist area in the center of the soiled linen;
-For soiled linens that are saturated with moisture, place them in a plastic bag followed
by tying or knotting the open end. The plastic bag containing wet linens should then be
placed in an approved laundry bag and closed before transporting to the proper designated
area.
5. Review of the TB Screening for Long Term Care Residents flowchart, revised 3/11/14,
provided by the Department of Health and Senior Services, showed the following:
-When a resident is admitted to a long term care facility and has no documentation of a
two-step TST, the facility must administer the first step TST within one month prior to or
one week after admission;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-Staff is to read the results of the first step TST within 48 to 72 hours after
administration;
-If the results were negative, staff must administer the second step TST within one to
three weeks;
-Staff is to read the results of the second step TST within 48 to 72 hours.
-Results must be read and documented in millimeters;
-The facility must complete an annual evaluation of residents to rule out signs and
symptoms of [MEDICAL CONDITION].
6. Review of Resident #4’s Immunization and [MEDICAL CONDITION] screening showed the
following:-Admission of 7/27/18;
-First TST administered on 8/12/18;
-No documentation of read date or results for first TST;
-Second TST administered on 8/14/18;
-Second TST read on 8/16/18 with a 0 negative result;
-Second TST administered too soon after first TST and not measured in mm.
4. Review of Resident #20’s Immunization and [MEDICAL CONDITION] screening showed the
following:
-Admission of 11/5/18;
-First TST administered on 11/5/18 to right forearm;
-Read on 11/8/18 as 0 negative to left forearm and not measured in mm;
-No evidence of second TST documented.
5. Review of Resident #15’s care plan dated 8/30/18, showed the following:
-Problem: Frequently incontinent of bladder and bowel and dependent for peri-care;
-Approach: Provide help with peri-care and changing of clothing.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument to be completed by the facility, and dated 11/28/18 showed the
following:
-Extensive assist of two staff for bed mobility;
-Extensive assist of one staff for personal hygiene;
-Always incontinent of bladder and bowel.
Observation on 1/17/19 at 5:45 A.M. showed the following:
-The resident lay in his/her bed;
-Certified Nurse Assistant (CNA) F and CNA G entered the room and pulled the resident’s
linens back to perform perineal care on the resident who had been incontinent of urine;
-The resident’s top sheet and blanket touched the floor;
-CNA G unfastened the urine soiled incontinent brief and completed peri care. CNA G then
tucked the bottom, urine soiled sheet under the resident and placed and tucked the clean,
incontinent brief under the soiled linens;
-CNA G and CNA F rolled the resident to his/her side;
-CNA F untucked and removed the soiled linens from under the resident and placed them
directly on the floor. CNA G then pulled the clean brief through;
-CNA F and CNA G, wearing the same soiled gloves, rolled the resident to his/her back and
both CNA F and CNA G fastened the clean brief;
-CNA G removed his/her gloves, washed his/her hands and exited the room;
-CNA G returned to the room with clean linens and applied gloves without washing hands;
-CNA G placed a clean fitted sheet on one side of the bed and rolled the resident to
his/her side;
-CNA F wearing the same soiled gloves pulled the bottom sheet through, secured it to the
mattress, exited the room, returned with a clean draw sheet in his/her hand wearing the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265508

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEGENDARY NURSING & REHABILITATION LLC

STREET ADDRESS, CITY, STATE, ZIP

809 EAST GORDON ST
MARSHALL, MO 65340

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
same soiled gloves and placed it on the bed;
-CNA F and CNA G rolled the resident and CNA G pulled the sheet;
-CNA F and CNA G covered the resident with the soiled linens which touched and lay on the
floor.
During interview on 1/17/19 at 6:05 A.M., CNA G said the following:
-Hands should be washed upon entering and exiting the room, when they become soiled and
with glove changes;
-Gloves should be changed when they become soiled;
-Clean items or surfaces touched by soiled hands would be considered contaminated;
-When linens touch or lay on the floor, they would be soiled and should not be placed back
on the bed;
-They had not completed the resident’s care following these principles.
During interview on 1/17/19 at 6:53 A.M., CNA F said the following:-Hands should be washed
when entering a resident’s room, when exiting and with glove changes;
-Gloves should be changed every time they are soiled;
-Soiled linens should not be placed on the floor;
-Resident linens should not touch or lay on the floor and if they did, they would be
contaminated
-They had not completed the resident’s care following these principles.
6. During interview on 1/18/19 at 5:50 P.M. the Director Of Nursing said the following:
-He/she would expect staff to give the first step followed by the second step ten days
later. Read each in 72 hours, and document the date and results in millimeters;
-Staff should wash their hands upon entering and exiting a resident’s room, anytime they
become soiled, when moving from dirty to clean tasks and with glove changes;
-Gloves should be changed when they become soiled;
-Resident bed linens should not touch the floor;
-Soiled linens should not be thrown on the floor, they should be placed in a bag;
-If and when linens become contaminated, they should be bagged and replaced with clean
linens;
-Staff should not touch clean items or surfaces with soiled hands/gloves.