Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
47% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to evaluate compliance with proper care per individual service plans and appropriate action and notification requirements following a resident fall and injury.
Findings
The facility failed to ensure proper care for one resident after a fall, including assessment and documentation of injuries, and failed to notify the resident's physician and family of the fall and injuries. The facility census was 35 at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan was not met as staff failed to assess a resident following a fall and did not document or report injuries properly.
19 CSR 30-86.047(37) Appropriate Action & Notification was not met as the facility failed to notify the resident's physician and family of a fall with injury.
Report Facts
Facility census: 35
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 1
Date: Jul 31, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication administration regulations following observations of medication errors by a Level One Medication Aide during a medication pass.
Findings
The facility failed to ensure a safe and effective medication system as a Level One Medication Aide administered medications incorrectly to three residents, including giving medications at the wrong time and using improper techniques. The Director of Nursing and Administrator reviewed the errors and instructed corrective actions to prevent recurrence.
Deficiencies (1)
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to implement a safe medication system as a Level One Medication Aide administered noon medications in error to three residents and documented administration times incorrectly.
Report Facts
Resident census: 29
Medication errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LIMA A | Level One Medication Aide | Named in medication administration errors |
| DON | Director of Nursing | Reviewed medication errors and supervised corrective actions |
| Administrator | Reviewed medication errors and stated expectations for staff |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 5
Date: May 7, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and electrical maintenance regulations at Chestnut Glenn Assisted Living by Americar.
Findings
The facility failed to document monthly pressure checks on fire extinguishers, correct faults in the fire alarm system, prevent storage of combustible materials blocking access to safety equipment, maintain the sprinkler system, and properly maintain electrical wiring. These deficiencies affected all 33 residents present during the inspection.
Deficiencies (5)
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to document monthly pressure checks on all fire extinguishers, including those in the kitchen and common areas.
19 CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults. The facility failed to correct a fault with the complete fire alarm system, which showed a trouble signal at D-4 smoke.
19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of. The facility stored unnecessary combustible materials blocking access to furnaces, electrical panels, and sprinkler systems.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to maintain the sprinkler system properly, with items stored within 18 inches of sprinkler heads interfering with operation.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to properly maintain electrical wiring, including use of a three-way plug adapter in a resident room.
Report Facts
Facility census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Hombal | Executive Director | Signed the statement of deficiencies and plan of correction |
| Maintenance Director | Interviewed regarding fire extinguisher checks, fire alarm faults, combustible materials, sprinkler system, and electrical wiring |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 1
Date: Aug 23, 2022
Visit Reason
The visit was conducted as a complaint investigation related to protective oversight and call light system functionality, with a plan of correction submitted to address the deficiencies.
Complaint Details
Complaint M000205971 was investigated. The violation was initially classified as Class I due to the extent of the violation but was lowered to Class II at exit after corrective actions were implemented.
Findings
The facility failed to provide protective oversight for one resident, resulting in a resident's suicide attempt due to a non-functional call light system. The call light system did not alert staff when activated, and staff were not properly carrying or responding to pagers linked to the call lights.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight for one resident by not having a functional call light notification system to alert staff of the resident's need for help. The resident used the call light cord to hang himself/herself, and the emergency call light system did not activate or alert staff.
Report Facts
Facility census: 27
Call light timeout: 30
Notification time: 15
Inspection Report
Routine
Census: 39
Deficiencies: 3
Date: Mar 14, 2022
Visit Reason
The inspection was conducted to assess compliance with fire safety and maintenance regulations at Chestnut Glenn-Assisted Living by AME.
Findings
The facility failed to maintain fire safety standards by storing combustibles near gas furnaces and water heaters, failing to document monthly fire extinguisher pressure checks, and using unapproved wastebaskets in resident rooms.
Deficiencies (3)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard: The facility stored combustibles blocking access to gas furnaces, water heaters, sprinkler controls, and electrical panels, creating a fire hazard.
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check: The facility failed to document monthly pressure checks on all fire extinguishers, with tags last inspected in July 2021 but no monthly signatures.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility used unapproved wastebaskets made of unlisted plastic, wicker, or metal mesh in resident rooms.
Report Facts
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| maintenance director | Interviewed regarding storage of combustibles and corrective actions | |
| administrator | Interviewed regarding fire extinguisher maintenance and wastebasket provision |
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 1
Date: Jun 7, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations governing assisted living facilities, specifically focusing on individualized service plans and resident care following observed deficiencies.
Findings
The facility failed to update individualized service plans (ISP) for residents after changes in their condition, including falls and injuries. Documentation and interventions to prevent further incidents were lacking, and staff did not consistently update care plans to reflect residents' needs or changes.
Deficiencies (1)
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to update individualized service plans for residents after changes in condition, including falls and injuries, and did not document interventions to prevent further incidents.
Report Facts
Facility census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Hannibal | Executive Director | Signed the plan of correction document |
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 1
Date: May 20, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to protective oversight at Chestnut Glenn Assisted Living by AME, following an incident involving a resident found injured after leaving the facility on voluntary leave.
Findings
The facility failed to provide protective oversight to one resident who left the premises on voluntary leave and was found injured outside. Staff did not respond timely to door alarms, and the resident sustained multiple injuries including bruising, a dislocated finger, and a large hematoma. The facility's procedures and staff response were inadequate to ensure resident safety.
Deficiencies (1)
19 CSR 30-86.047(35), Protective Oversight: The facility failed to provide twenty-four hour protective oversight for residents departing on voluntary leave. Staff did not respond to door alarms promptly, resulting in a resident being found injured outside with bruises, a dislocated finger, and other injuries.
Report Facts
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA D | Certified Medication Aide | Named in the finding related to response to resident emergency and oversight |
| DON C | Director of Nursing | Called for ambulance and involved in emergency response |
| LIMA E | Level One Medication Aide | Interviewed regarding emergency call and response |
Inspection Report
Renewal
Census: 45
Deficiencies: 6
Date: Apr 2, 2019
Visit Reason
The inspection was a licensure inspection conducted on 04/02/2019 to assess compliance with fire safety, hazardous area requirements, sprinkler system maintenance, emergency lighting, wastebasket requirements, heating system, and electrical wiring standards at Chestnut Glenn Assisted Living.
Findings
The facility was found deficient in multiple areas including hazardous area separation, sprinkler system maintenance, emergency lighting operation, use of fire-resistant wastebaskets, prohibition of portable heaters, and electrical wiring safety. Several Class II deficiencies were cited, affecting all 45 residents present during the inspection.
Deficiencies (6)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to ensure hazardous areas were separated by smoke-resistant self-closing doors. The kitchen door and laundry room door did not have self-closing devices, and the kitchen pass-through window did not provide smoke-resistant separation.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to maintain the sprinkler system in accordance with NFPA 13. Sprinkler heads were found covered in grease and debris, and escutcheon rings were missing.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. Emergency lights in multiple locations failed to illuminate when tested, including dining room, hallways, and exit doors.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility used wastebaskets that were not metal or UL/FM fire-resistant rated in resident rooms and common areas.
19 CSR 30-86.032(10) Heaters - Approved Label, Venting, No Portable. The facility failed to ensure no portable space heaters were used. A portable fireplace was found plugged in and in use in the lobby.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to maintain electrical wiring in good repair. Non-GFCI outlets, loose outlets, and use of multiple adapters and power strips without overload protection were observed.
Report Facts
Facility census: 45
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 5
Date: Mar 14, 2018
Visit Reason
The document is a Plan of Correction submitted by Chestnut Glenn Assisted Living following a state survey conducted on 03/14/2018. It addresses deficiencies identified during the inspection related to tuberculosis screening, personnel records, medication systems, controlled substances reconciliation, and ventilation hood cleanliness.
Findings
The facility failed to ensure proper tuberculosis screening for residents and staff, maintain complete personnel records including physician statements, provide a safe and effective medication system, reconcile controlled substances by at least two people, and maintain clean ventilation hoods and surrounding areas. Multiple residents and employees were affected by these deficiencies.
Deficiencies (5)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure three residents and two employees had completed required two-step tuberculosis testing and annual TB symptom reviews. Documentation was incomplete or missing for several residents and employees.
19 CSR 30-86.047(20)(I) Personnel Record-physician statement: The facility failed to maintain written statements signed by a licensed physician or designee for one new employee indicating ability to work in a long-term care facility.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to provide a safe medication system for seven residents when a medication aide did not read pharmacy labels or properly document medication administration.
19 CSR 30-86.047(51)(B)(2) Controlled Substances-Reconcile by Personnel: The facility failed to ensure controlled substance inventories were reconciled by at least two people as required by policy.
19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable: The facility failed to maintain the range hood exhaust system and surrounding stainless steel surfaces clean and free of grease and debris.
Report Facts
Facility census: 47
Completion dates: All corrective actions completion dates are 04/20/2018
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