LEGACY LIVING.

Missouri Department of Health and Senior Services STATEMENT OF DEFICHENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER; 14084C NAME OF PROVIDER OR SUPPLIER : ‘LEGACY LIVING SUMMARY. STATEMENT. OF DEFICIENCIES (EACH DEFICIENCY MUST: BE PRECEDED BY FULL REGULATORY OR’LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG 19 CSR 30-86.047(46) Safe & Effective Medication System -A4797| The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptabie nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. Alt individuals who administer medication shalt be trained in medication administration and, if nota physician or a licensed nurse, shall be a certified medication technician or fevel |! medication aide. Wl This regulation is not met as evidenced by: Class il Based on observation, interview, and record review the facility failed to develop and implement a safe and effective system of medication use, when Level One Medication Aide (.4MA) A failed to observe four of four sampled residents, (Resident #1, #2, #3, and #4) take their medications. The facility census was 17. Missouri Department of Heaith and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATI "p SIGNATURE 6699 STATE FORM B. WING (X2} MULTIPLE CONSTRUCTION A. BUILDING: PRINTED; 03/02/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/19/2026 ID PREFIX TAG STREET ADDRESS, cry, STATE, ZIP CODE 800 LEGACY LANE CHILLICOTHE, MO 64601 IPMW11 (XS) COMPLETE DATE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) TITLE (X6) DATE lf continuation sheet 1 of 5 PRINTED: 03/02/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 14084C — 02/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 500 LEGACY LANE CHILLICOTHE, MO 64601 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) LEGACY LIVING A4797 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if nota physician or a licensed nurse, shall be a certified medication technician or level | medication aide. IAI This regulation is not met as evidenced by: Class II Based on observation, interview, and record review the facility failed to develop and implement a safe and effective system of medication use, when Level One Medication Aide (L1MA) A failed to observe four of four sampled residents, (Resident #1, #2, #3, and #4) take their medications. The facility census was 17. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IPMW111 If continuation sheet 1 of 5 PRINTED: 03/02/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 14084C — 02/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 500 LEGACY LANE CHILLICOTHE, MO 64601 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) LEGACY LIVING Continued From page 1 Review of the facility's undated policy titled, "Administering Medications," showed all medications were to be administered in a safe and timely manner. 1. Review of Resident #1's record showed diagnoses included anxiety, depression, cognitive communication deficit, and dementia (a decline in ability of memory, thinking, and reasoning). Review of the resident's February 2026 Physician's Order Sheet (POS) showed: -Order dated 09/18/25 Aspirin (medication used for high blood pressure) 81 milligrams (mg) once daily at 12:00 P.M.; -Order dated 11/06/25 Trazodone (medication used for depression) 25 mg four times daily at 7:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.; -Order dated 09/18/25 Lisinopril (medication used for high blood pressure) 10 mg once daily at 12:00 P.M.. Observation on 02/19/26 at 11:30 A.M. showed L1MAA prepared the resident's Aspirin, Trazodone, and Lisinopril from their original containers into a medication cup, took the medication cup with medications in it to the resident sitting at the dinner table in the dining room, sat the medication cup in front of the resident and walked away without observing the resident ingesting his/her medications. 2. Review of Resident #2's record showed diagnoses included anxiety, depression, heart failure, and Alzheimer's (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain). Review of the resident's February 2026 POS Missouri Department of Health and Senior Services STATE FORM 6899 IPMW11 If continuation sheet 2 of 5 PRINTED: 03/02/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 14084C — 02/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 500 LEGACY LANE CHILLICOTHE, MO 64601 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) LEGACY LIVING Continued From page 2 showed: -Order dated 12/03/25 Ferrous Sulfate (medication used for low iron) 325 mg once daily at 12:00 P.M.; -Order dated 10/06/25 Omega-3 Fish Oil Oral (medication used to reduce inflammation) 1000 mg once daily at 12:00 P.M.. Observation on 02/19/26 at 11:35 A.M. showed L1MAA prepared the resident's ferrous sulfate and omega 3 fish oil, from their original containers into a medication cup, took the medication cup with medications in it to the resident sitting at the dinner table in the dining room, sat the medication cup in front of the resident and walked away without observing the resident ingesting his/her medications. 3. Review of Resident #3's record showed diagnoses included heart failure and high blood pressure. Review of the resident's February 2026 POS showed: -Order dated 10/16/25 Biotin (medication used for dry mouth) 5000 micrograms (mcg) once daily at 12:00 P.M.; -Order dated 10/04/25 Multivitamin (supplement used for vitamin deficiency) one tablet daily at 12:00 P.M.; -Order dated 01/08/26 Potassium Chloride (medication used for low potassium) 10 milliequivalent (MEQ) once daily at 12:00 P.M.. Observation on 02/19/26 at 11:40 A.M. showed L1MAA prepared the resident's biotin, multivitamin, and potassium chloride, from their original containers into a medication cup, took the medication cup with medications in it to the resident sitting at the dinner table in the dining Missouri Department of Health and Senior Services STATE FORM 6899 IPMW11 If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 14084C NAME OF PROVIDER OR SUPPLIER LEGACY LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHILLICOTHE, MO 64601 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 room, sat the medication cup in front of the resident and walked away without observing the resident ingesting his/her medications. 4. Review of Resident #4's record showed diagnoses included heart failure, respiratory failure, and bladder cancer. Review of the resident's February 2026 POS showed: -Order dated 07/27/25 Calcium Acetate (medication used for anemia) 667 mg three times daily at 7:00 A.M., 11:45 A.M., and 5:00 P.M.. Observation on 02/19/26 at 11:45 A.M. showed L1MAA prepared the resident's calcium from its original container into a medication cup, took the medication cup with medication in it to the resident sitting at the dinner table in the dining room, sat the medication cup in front of the resident and walked away without observing the resident ingesting his/her medication. During an interview on 02/19/26 at 11:50 A.M. L1MAA said: -He/She knew he/she was expected to watch the residents take their medications; -When administering medications to the residents in the dining room, most residents did not want to take their medication right away and wanted to get their food and start eating before taking the medications; -He/She would make rounds around the dining room during meal time to ensure the residents took their medications and did not leave them behind; -He/She had no way to confirm the residents took the medications themselves or if the person siting next to them took the medications with not observing them ingest them in front of him/her Missouri Department of Health and Senior Services STATE FORM 6899 IPMW11 PRINTED: 03/02/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/19/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 500 LEGACY LANE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 5 PRINTED: 03/02/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 14084C — 02/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 500 LEGACY LANE CHILLICOTHE, MO 64601 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) LEGACY LIVING Continued From page 4 when he/she administered them. During an interview on 02/19/26 at 1:30 P.M. the Licensed Practical Nurse (LPN) said he/she expected all medication staff to watch all residents take their medications to ensure proper administration. During an interview on 02/19/26 at 1:36 P.M. the Administrator said he/she expected all medication staff to observe every resident ingest their medication before moving on to the next resident in that medication pass. Missouri Department of Health and Senior Services STATE FORM 6899 IPMW11 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: Legacy Living Street Address, | 549 Legacy Lane Chillicothe MO 64601 City, Zip: Date of Survey: Feb 19, 2026 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A4797 To correct the deficient practice affecting the residents on the Resident roster and to prevent the deficient practice occurring to Those resident having the potential to be affected the following Interventions will be put in place: Staff will be educated in in service 3/16/26 that any staff member Passing meds shall watch the resident ingest the meds and not Leave the medication unattended with the resident. 3/16/26 The Administering Medications Policy and Procedure was up- Dated 2/20/2026 to include staff administering medications to residents shall watch the ingestion of the medication by the 2/20/26 resident. Audits will be completed by administrator/LPN/or designee 4x/week x4 weeks, 2x/week x 2 weeks by 4/4/26 then quarterly 3/23/26 and prn To ensure the deficient practice has been corrected Audits will be reviewed monthly and prn in monthly safety/QA Meeting to ensure the deficiency has been corrected. Amended 3/11/26 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.