Avenir At Mark Twain
Inspection Findings
F-Tag F0550
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
assisting the resident;-The resident poked a hole in the seal with a finger in order to open his/her drink.
During an interview on 8/18/25 at 9:52 A.M., the resident said no staff ever help him/her in the dining room.
They walk away before he/she can even finish asking for help. During an interview with on 8/20/25 at 1:48 P.M., the DON and Administrator said any staff member can assist a resident with opening a food package or retrieving new silverware. They expected staff to assist residents with meals and not ignore the residents or walk away while the residents are talking. 5. Review of Resident #5's medical record, showed:-Diagnoses included hypertension (high blood pressure), end stage renal disease (ESRD, permanent kidney failure requiring transplant or dialysis for survival), history of transient ischemic attack (TIA, a temporary interruption in blood flow to the brain causing stroke-like symptoms) and Type 2 diabetes.
Review of the resident's care plan, in use at the time of the survey, showed:-Focus: the resident is at risk for falls as evidenced by a fall the resident suffered on 3/5/25; -Interventions: Ensure personal items were within the resident's reach. Ensure the resident's call light is within reach for the resident to use in order to ask for assistance. During an interview on 8/18/25 at 7:40 A.M., the resident said a few days ago a member of the night shift, CNA P, got into a power struggle with him/her over the call light. The resident said CNA P attempted to pull the call light away from him/her in order to prevent him/her from using it for the rest of the night. The resident said the staff member told him/her this would prevent the resident from pressing it all night and bothering staff on the hall. The resident said he/she felt disrespected by the staff member during that interaction, and these undignified interactions happen with other staff members as well. During an
interview on 8/18/25 at 8:39 A.M., the Administrator said the resident came to his office on 8/17/25 to discuss the alleged incident with CNA P. The resident was assessed and found without injury. The resident did not allege abuse occurred and did not state he/she was in pain but felt the treatment given to him/her by CNA P was undignified. CNA P was removed from the future schedule at that time while the facility investigated the incident. The Administrator had not been able to successfully contact CNA P to discuss the alleged incident. 2588074 25793742572384161199516119822591662
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenir at Mark Twain
11988 Mark Twain Lane Bridgeton, MO 63044
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-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
During an interview on 8/20/25 at 1:27 P.M., the DON said the Charge Nurse on the floor oversees the residents' weights. The RA was responsible to obtain the weights and place them in the EMR. All weights were expected to be added into the EMR timely and accurately to avoid any inaccuracy about the weights.
She was not aware that the RA was not placing the weights directly into the EMR. 3. Review of Resident #9's medical record showed diagnoses that include atrial fibrillation (irregular heartbeat), stroke, slurred speech, pacemaker, heart failure, infection of cardiac devices, and muscle weakness. Review of the resident's request transportation form showed:-On 5/20/25 , eye doctor appointment;-On 5/27/25, cardiology (heart) doctor appointment;-On 5/30/25, infectious disease doctor appointment-On 7/15/25 , foot and ankle surgery doctor appointment;-On 8/14/25, wellness visit appointment;-On 8/19/25, foot and ankle surgery doctor appointment. Review of the resident's progress notes showed:-On 5/20/25, no documentation related to the eye doctor's appointment;-On 5/27/24, no documentation related to the cardiology doctor's appointment;-On 5/30/25 at 9:38 A.M., the nurse received a call that the resident arrived late to the appointment, and the appointment was rescheduled for 8/4/25;-On 7/15/25, no documentation related to the foot and ankle surgery doctor's appointment;-On 8/4/25, no documentation related to the rescheduled infectious disease doctor's appointment;-On 8/14/25, no documentation related to the wellness visit appointment;-On 8/19/25, no documentation related to the foot and ankle surgery doctor's appointment. 4. Review of Resident #68's medical record showed diagnoses that included stroke, high blood pressure, edema (swelling), breast cancer, cardiomegaly (weakened and enlarged heart), atrial fibrillation, and lumbar (lower back) radiculopathy (nerve irritation or compression that causes pain). Review of the resident's request transportation forms showed:-On 5/15/25, primary care doctor appointment;-On 5/20/25, eye doctor appointment;-On 6/13/25, pain management doctor appointment;-On 6/17/25, neurology (brain and nervous system) doctor appointment;-On 7/10/25, pain management doctor appointment. Review of the resident's progress notes showed:-On 5/15/25, no documentation related to the primary care doctor's appointment;-On 5/20/25, no documentation related to the eye doctor's appointment;-On 6/13/25, no documentation related to the pain management doctor's appointment;-On 6/17/25, no documentation related to the neurology doctor's appointment;-On 7/10/25, no documentation related to the pain management doctor's appointment. During an interview on 8/19/25 at approximately at 10:15 A.M., the resident said he/she has many doctor appointments due to his/her many medical conditions. Some of his/her appointments are missed due to transportation delays. 5. During an interview
on 8/19/25 at 9:25 A.M., LPN J said when the residents go out to any appointments, there should be a note that the resident left for the appointment and when the resident returned. The return note should contain
the condition of the resident, any information the resident said about the appointment and any new orders related to the appointment and when the next appointment is scheduled; all that information should be documented in the progress notes. 6. During an interview on 8/20/25 at 1:27 P.M., the Administrator and DON said a progress note is expected to be added every time the resident leaves for an appointment and when they return. The notes are expected to include when the resident left and where they were going.
When the resident returns, a note is expected to include what time the resident returned and if there are any new recommendations, orders or appointments that need to be added to the resident's medical record.
If the resident does not go to the appointment a note is expected to be added related to the missed appointment. 1611982
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenir at Mark Twain
11988 Mark Twain Lane Bridgeton, MO 63044
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-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
week. Observation on 8/19/2025 at 8:38 A.M., showed the resident had oily hair and dirty nails with matter underneath the nails. During an interview on 8/20/25 at 7:48 A.M., CNA M said he/she would expect the resident to have clean nails and hair. He/She would expect the resident to receive at least two showers a week. During an interview on 8/20/25 at 8:01 A.M., RN C said nursing staff should ensure the resident receives at least two showers or bed baths a week. He/She would expect the resident's hair and nails to be washed. During an interview on 8/20/2025 at 3:00 P.M., the DON and Administrator said they would expect
the resident to recieve at least two showers or bed baths a week. They would expect the resident's hair and nails to be cleaned during their showers or as needed. 3. Review of Resident #28's admission MDS, dated , 7/3/25, showed:-Moderately impaired cognition;-Diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis) affecting the dominant right side, diabetes, and acute kidney failure. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident has an ADL self-care performance deficit;-Goal: The resident will maintain current level of function through the next review date;-No interventions for eating assistance listed. Observation on 8/18/25 at 8:40 A.M., showed the resident in the dining room for breakfast. The resident struggled to open a carton of juice with one hand.
He/She poked a hole in the seal with a finger in order to open his/her drink. During an interview on 8/18/25 at 9:52 A.M., the resident said no staff ever help him/her in the dining room. Observations on 8/19/25 during lunch, showed:-At 12:30 P.M., while in the dining room for lunch, the resident picked up his/her napkin and his/her fork fell on the ground;-At 1:10 P.M., the resident started to eat his/her pasta with his/her hands.
During an interview on 8/20/25 at 7:48 A.M., CNA M said he/she would expect staff to assist the resident with any needs he/she might have during meals. The resident is someone who needs help due to low mobility in his/her right arm. During an interview on 8/20/25 at 8:01 A.M., RN C said he/she would expect staff to assist the resident during meals with opening drinks and positioning the resident's wheelchair up to
the table. He/She would expect the resident's care plan to reflect his/her ADL needs. During an interview on 8/19/25 at 12:46 P.M., the DON said she would expect all staff in the dining room for meals to assist residents with opening drinks and bringing residents new silverware. She would expect nursing staff to inform her if residents are having a hard time feeding themselves so the residents can be evaluated for ADL care needs. 25880741612001
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenir at Mark Twain
11988 Mark Twain Lane Bridgeton, MO 63044
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-Tag F0804
F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
contained a scoop of scrambled eggs and a biscuit. During an interview, the resident said his/her food was served cold and it was not enough to eat. At 9:05 A.M., CNA HH removed the resident's breakfast tray. As he/she was leaving the room, the resident said his/her food was nasty. CNA HH laughed and said he/she would remove the tray for the resident. CNA HH did not offer to get the resident an alternate. Observation
on 8/18/25 at 8:46 A.M., showed the resident in bed with a tray of breakfast on his/her bedside table, consisting of a scoop of scrambled eggs and a donut. No dietary slip on the breakfast tray. During an interview, the resident said this is ridiculous. He/She is hungry and did not get served enough to eat.
He/She is upset, tired and hungry. 7. Review of Resident #54's medical record, showed:-Cognitively intact;-Diagnoses included acute kidney failure, muscle weakness and depression. During an interview on 8/14/2025 at 12:03 P.M., the resident said the food is horrible. He/She said food temperatures are cold when food is delivered. He/She said two months ago, the kitchen served raw meat to the residents. 8.
Review of Resident #60's comprehensive MDS, dated [DATE REDACTED], showed:-Moderate cognitive impairment;-Setup or clean-up assistance required for eating;-Diagnoses included diabetes, adult failure to thrive, heart disease, chronic obstructive pulmonary disease (lung disease) and dementia. Observation on 8/18/25 at 8:47 A.M., showed the resident eating breakfast in his/her room. Breakfast consisted of one donut and one scoop of scrambled eggs. No dietary slip was on the tray. During an interview, the resident said his/her breakfast was not good. The donut was not sweet and it was dry. The food served at the facility does not taste good. It is always served cold when it should be hot. 9. Review of Resident #64's quarterly MDS, dated [DATE REDACTED], showed:-Cognitively intact;-Diagnosis included type two diabetes, muscle weakness and major depressive disorder. During an interview on 8/14/2025 at 1:48 P.M., the resident said the food is awful. The coffee is not hot when served. Staff do not offer refills. 10. Review of Resident #68's quarterly MDS, dated [DATE REDACTED], showed:-The resident is cognitively intact;-Diagnoses include stroke, high blood pressure and heart failure. During an interview on 8/14/25 at 5:58 P.M., the resident said he/she does not eat the food in the facility. The food does not look appetizing, and it is often cold. The food is not nutritious and does not provide the 5 food groups. The resident's family brings in meals for him/her every day. 11.
Observation on 8/14/25 at 5:37 P.M., of dinner on the [NAME] hallway, showed:-Baked beans measured 103.2 degrees F;-Barbeque (BBQ) burger measured 92.3 degrees F. The meat was chewy. Observation on 8/14/25 at 5:53 P.M., of dinner on the East hallway, showed:-BBQ burger measured 95.6 degrees F. The meat was bland and chewy. 12. During a group interview on 8/18/25 at 11:03 A.M., six out of six residents, whom the facility identified as alert and oriented, said there are ongoing issues with dietary. Food that is supposed to be hot is served cold. Food is served that is not cooked all the way through. They have discussed this in resident council meetings and the dietary issues have continued. During an interview on 8/14/25 at 11:43 A.M., CNA B said the food served at the facility is terrible, not good. The residents don't like the food and won't eat it. The portions are small and residents do not get enough to eat. The food is always served cold when it should be hot. During an interview on 8/19/25 at 1:03 P.M., Dietary Aide F said food should be served at a safe and palatable temperature and should taste good. During an interview on 8/19/25 at 12:44 P.M., the Dietary Manager said food should be delivered to residents at a safe and palatable temperature to prevent illness. She said the food has not been served at the required temperature due to broken kitchen appliances not warming the food. During an interview on 8/20/2025 at 2:12 P.M., the Administrator and Director of Nursing (DON) said they expected food to be served to residents at a safe and palatable temperature. They expected food to be palatable. They expected staff to heat up food if it is not at the appropriate temperature. 161200116119951611992
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenir at Mark Twain
11988 Mark Twain Lane Bridgeton, MO 63044
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-Tag F0806
F 0806
options. 16119952588074
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenir at Mark Twain
11988 Mark Twain Lane Bridgeton, MO 63044
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-Tag F0947
F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Based on interview and record review the facility failed to provide documentation of ongoing educational training provided to active Certified Nursing Aides (CNAs), totaling no less than 12 hours per year, for four of six sampled active CNAs. Insufficient training documentation was provided for four of six sampled CNAs.
The sample was 18. The census was 75.1. Review of CNA E's CNA Annual In-Service Training Log, showed:-Inservices completed each month from January 2025 to June 2025, with each inservice totaling one hour;-No record of inservices completed prior to January 2025. 2. Review of CNA Z's CNA Annual In-Service Training Log, showed:-Inservices completed each month from January 2025 to June 2025, with each inservice totaling one hour;-No record of inservices completed prior to January 2025. 3. Review of CNA AA's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at the facility. 4. Review of CNA BB's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at the facility. 5. Review of CNA CC's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at
the facility. 6. Review of CNA DD's CNA Annual In-Service Training Log, showed:-No record of inservices completed for the past year, from hire date to hire date, while employed at the facility. 7. During an interview
on 8/19/25 at 8:52 A.M., the Director of Nursing (DON) said she was unable to find annual education logs for four of the six sampled CNAs and does not have access to any annual trainings completed by employees prior to January, 2025. The DON said the previous administration walked out of the building with numerous documents and believes CNA trainings may have been among them. Ensuring annual education is completed by CNAs is the responsibility of the DON, and all CNAs at the facility should receive 12 hours of education annually per regulation guidelines.8. During an interview on 8/20/25 at 1:48 P.M the Administrator and DON said they expected all CNAs at the facility to receive 12 hours of ongoing education annually per regulation guidelines. It is believed the previous DON took inservice records and education documentation with them when resigning from the position.
Event ID:
Facility ID:
If continuation sheet
AVENIR AT MARK TWAIN in BRIDGETON, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BRIDGETON, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVENIR AT MARK TWAIN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.