PLEASANT VIEW.

PRINTED: 11/04/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/GLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: ’ COMPLETED 25358 B. WING 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 641 EUCLID AVENUE HANNIBAL, MO 63401 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) 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) PLEASANT VIEW A3201] 19 CSR 30-86.032(2) Substantially Constructed &| A3201 Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing, IV/Ill This regulation is not met as evidenced by: Class {I* Based on observation and interview, the facility failed to maintain the building in good repair when the facility failed to repair a large 12 inch by 15 inch hole in the ceiling of the upstairs resident activities room. The facility census was 29. Observation on 10/22/25 at 10:25 A.M. of the ceiling in the activities room located on the second-floor nearest the east wall showed the following: -A large hole, approximately 12 inchs by 15 inches, covered with plastic; -Plastic was taped to ceiling to cover the open area; ~A five gallon bucket on the floor beneath the hole in the ceiling filled with approximately four to five | inches of water and plaster debris from the ceiling; -Large water stains on the ceiling around the hole in the ceiling and water stains just west of the hole; -The plastic on the ceiling moved in and out showing air flow from the hole; -The facility used the room for resident activities. During interview on 10/22/25 at 02:15 P.M., the Administrator said the following: -The hoie in the ceiling had been there since before he/she began working as the Administrator Missouri Department of Health and Senlor Services LABQRATORY DIREC ORp OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE 2022-5 tinuation sheet 1 of 2 8889 X98X14 PRINTED: 11/04/2025 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 25358 B.WING 40/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 641 EUCLID AVENUE HANNIBAL, MO 63401 (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) PLEASANT VIEW A3201| 18 CSR 30-86.032(2) Substantially Constructed &) A3201 Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to maintain the building in good repair when the facility failed to repair a large 12 inch by 15 inch hole in the ceiling of the upstairs resident activities room. The facility census was 29. Observation on 10/22/25 at 10:25 A.M. of the ceiling in the activities room located on the second-floor nearest the east wall showed the following: -A large hole, approximately 12 inchs by 15 inches, covered with plastic; -Plastic was taped to ceiling to cover the open area; -A five gallon bucket on the floor beneath the hole in the ceiling filled with approximately four to five inches of water and plaster debris from the ceiling; -Large water stains on the ceiling around the hole in the ceiling and water stains just west of the hole; -The plastic on the ceiling moved in and out showing air flow from the hole; -The facility used the room for resident activities. During interview on 10/22/25 at 02:15 P.M., the Administrator said the following: -The hole in the ceiling had been there since before he/she began working as the Administrator Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE THLE {X6) DATE OO STATE FORM sees X9SX11 if continuation sheet 4 of 2 Missouri Department of Health and Senior Services PRINTED: 11/04/2025 FORM APPROVED STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 25358 B. WING 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 641 EUCLID AVENUE PLEASANT VIEW HANNIBAL, MO 63401 (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 A3201 Continued From page 1 at the facility in July of 2025; -She had contacted the facility corporate office in July of 2025 regarding the ceiling; -She was told there was a condensation issue from the air conditioning unit; -The ceiling has been repaired multiple times over the past year but it kept leaking and the previous maintenance staff didn't know how to fix the issue; ~ It was her expectation the building be in good repair for the safety of the residents and for the aesthetics of the facility. * The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 X9SX11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: Pleasant View Assisted Living Facility Street Address, | 644 Euclid Ave. Hannibal, MO. 63401 City, Zip: Date of Survey: 10/22/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 25358 iD PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION DATE SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) | LT This Pian of Correction is submitted as required under State regulations and statues applicable to jong-term care providers. This Plan of Correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of the plan does not constitute an agreement by the facility that the surveyors’ findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of the deficiencies cited are correctly applied. ee Upon further inspection by maintenance, the issue was identified as a disconnected drainpipe from an ac unit, causing the hole in the ceiling. Pipe was extended and reconnected. Water was cleaned up and the hole in the ceiling has-been ia] 10/25 replaced. Maintenance will continue to monitor the ceiling * throughout the building once a week for the next 3 months, then | once monthly to maintain safe conditions. ee Se Se I NU, es ee es a eT | OU Rn OT a Te es nO ee Beene TTEEOUT TIED a SE nn en UnInnnnnUIININUIDUISTnInIUUIISOUInEI I J eS a CRETE PO | a Po The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the pian of correction being submitted on this form.

PRINTED; 11/27/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 25358 B.WING 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 641 EUCLID AVENUE HANNIBAL, MO 63401 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION {X5} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE Otte TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE PLEASANT VIEW A2286) 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview the facility failed to use only metal or UL- or FM-fire-resistant rated wastebaskets. The facility census was thirty-three (33). This affected thirty-three (33) of thirty-three (33) residents. resident room #165 showed 4 non-rated plastic trash cans. Observation on 11/15/23 at 11:16 A.M. showed Metal trash can replaced plastic one 11-24-23 resident room #135 with a non-rated plastic trash can. Observation on 11/15/23 at 11:17, showed resident Metal trash can replaced plastic one 11-24-23 room #133 with a non-rated plastic trash can. resident room #232 with a non-rated plastic trash can. Observation on 11/15/23 at 11:24 A.M., showed Metal trash can replaced plastic one resident room #233 with a non-rated plastic trash cans. Observation on 11/15/23 at 11:28 A.M., showed Metal trash can replaced plastic one resident room #236 with a non-rated plastic trash cans. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S S) (x6) DATE STATE FORM if continuation sheet 1 of 4 NAME OF PROVIDER OR SUPPLIER Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CLIA [IDENTIFICATION NUMBER: 25358 (X2} MULTIPLE CONSTRUCTION A, BUILDING: B, WING 641 EUCLID AVENUE PLEASANT VIEW (x4) ID PREFIX TAG HANNIBAL, MO 63401 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2286 |} Continued From page 1 Observation on 11/15/23 at 11:32 A.M., showed resident room #240 with a non-rated plastic trash cans. Observation on 11/15/23 at 11:41 A.M., showed resident room #245 with a non-rated plastic trash cans. Observation on 11/15/23 at 11:42 A.M., showed resident room #247 with 5 non-rated plastic trash cans. Observation on 11/15/23 at 11:43 A.M., showed resident room #246 with 3 non-rated plastic trash cans. Observation on 11/15/23 at 11:45 A.M., showed resident room #248 with 4 non-rated plastic trash cans, Observation on 11/15/23 at 11:46 A.M., showed resident room #250 with a non-rated plastic trash cans, Observation on 11/15/23 at 11:53 A.M., showed resident room #253 with 3 non-rated plastic trash cans. Observation on 11/15/23 at 11:55 A.M., showed resident room #255 with 4 non-rated plastic trash cans. During an interview on 11/15/23 at 12:30 P.M., the administrator stated she would get new trash cans ordered and replaced. A3211] 19 CSR 30-86.032(10) Heaters-Approved Label, Missouri Department of Health and Senior Services STATE FORM 6899 iD PREFIX TAG PRINTED: 11/27/2023 FORM APPROVED {X3} DATE SURVEY COMPLETED 41/15/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE Metal trash can replaced plastic ones Metal trash can replaced plastic ones Metal trash cans replaced plastic ones Metal trash cans replaced plastic ones Metal trash cans replaced plastic ones Metal trash cans replaced plastic ones Metal trash cans replaced plastic ones Metal trash cans replaced plastic ones 152B11 (x8) COMPLETE DATE 11-24-23 11-24-23 11-24-23 11-24-23 11-24-23 11-24-23 11-24-23 If continuation sheat 2 of 4 PRINTED: 11/27/2023 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 25358 B.WING 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 641 EUCLID AVENUE HANNIBAL, MO 63401 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE atoll TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE FICIENCY’ PLEASANT VIEW Continued From page 2 Venting, No Portable in newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wail heaters are used, adequate guards shall be provided to safeguard residents. 1/Hi This regulation is not met as evidenced by: Class II Based on observation and interview the facility failed to prohibit the use of portable heaters of any kind. The facility census was thirty-three (33) and this affected thirty-three (33) of the thirty-three (33). Observation on 11/15/23 at 11:53 A.M. showed Missouri Department of Health and Senior Services STATE FORM 6899 152B41 |f continuation sheet 3 of 4 PRINTED: 11/27/2023 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 25358 B. WING 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 641 EUCLID AVENUE HANNIBAL, MO 63401 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE Oe TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE PLEASANT VIEW Continued From page 3 resident room #253 having a portable space heater. During an interview on 11/15/23 at 12:30 P.M., the administrator removed the space heater and stated she would get it to the family. Space heater was removed from #253 and put in a locked storage closet. On 11-24-23 the heater was moved from locked closet and moved to the locked Mainentance room. Family is to pick up and take home on next visit. 11-28-23 Missouri Department of Health and Senior Services STATE FORM 8899 152B11 If continuation sheet 4 of 4 PLAN OF CORRECTION Name: Street Address, City, Zip: Pleasant View Assisted Living 641 Euclid Ave., Hananibal, MO 63401 Date of Survey: November 15, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE 11-24-23 place with the metal trash cans stored in the storage room upstairs. All trash cans meets OSHA and qualifies under NFPA Life Safety Code. A3211 On 11-15-23, portable heater was removed from room #253 & put into a locked storage closet. The heater has since been removed from locked closet and put in the storage room/mainentance | | i |_| room which is locked at all times. Family has been notified to | ids take home with them when they come to visit. 1-28-23 | | Cs 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.