Avenir At Mark Twain

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interview and record review, the facility failed to notify the resident's representative after the resident fell, for one out of three residents sampled for falls. (Resident #1). The census was 75.Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/10/25, showed:-Cognitive intact;-Diagnoses included: diabetes, high blood pressure, end stage renal failure (ESRD, chronic irreversible kidney failure) dependence on renal dialysis (a life-sustaining treatment that filters waste products and excess fluid from the blood when the kidneys are no functioning properly);-Mobility devices: wheelchair and walker;-One fall since admission/entry or reentry;-Partial/moderate assistance (helper does less than half of the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for chair/bed-to-chair transfers.

Review of the resident's care plan in the use at the time of survey, showed:-Focus: The resident has had an actual fall with no Injury, minor injury, serious injury;-Interventions: On 11/9/25, resident encouraged to use call light when needing any assistance; Monitor/document /report as needed times 72 hours to physician for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. Review of the progress notes dated 11/9/25 at 7:20 P.M., showed the nurse was called down to room, the resident was on the floor in the bathroom. States he/she did not lock his/her wheelchair before getting back in it from using the restroom. Vitals stable. Denies hitting his/her head. Able to move extremities within resident's normal limits. Alert and oriented times four (person, place, time and situation). Neurological checks within normal limits. Denies pain. Message left for Medical Doctor (MD);-There was no documentation showing the resident's representative was notified. During an interview

on 12/18/25 at 11:05 A.M., Licensed Practical Nurse (LPN) A said if a resident fell, he/she would assess

the resident and get the resident up, if the resident was able. The Director of Nursing (DON), MD and the resident representative (RP) are then notified. During an interview on 12/18/25 at 11:35 A.M., LPN B said if

a resident fell, he/she would do a head-to-toe assessment and notify the MD and the RP. Falls are documented under risk management, and in the progress notes. During an interview on 12/19/25 at 10:41 A.M., the Assistant Director of Nursing (ADON) said staff should notify management, the physician and the family when a resident falls and document it in the progress notes. During an interview on 12/19/25 at 1:30 P.M., the Administrator said she had no documentation to show the family was notified after the fall. She would expect the nurse to assess any resident who falls and notify the physician and family, and document it. 2688707

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

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

12/19/2025

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's MAR dated 12/1/25 through 12/18/25, showed:-A physician order for Humalog, inject as per sliding scale: if 181 - 220 = 2 Give 2 units; 221 - 260 = 3 Give 3 units; 261 - 300 = 4 Give 4 units; 301 - 350 = 5; give 5 units, subcutaneously before meals for diabetes, (blood sugar) greater than 350 give 6 units and notify physician;-Documentation showed: blood glucose monitoring was scheduled and completed at 6:30 A.M., 8:00 A.M. and 11:00 A.M.;-No blood glucose monitoring completed before supper. Review of the progress notes dated 11/18/25 through 12/18/25, showed no documentation showing the physician order was changed. During an interview on 12/19/25 at 10:41 A.M. the ADON said she would expect staff to complete the blood sugar checks before each meal as ordered. 3. Review of Resident #1's admission MDS, dated [DATE REDACTED], showed the resident cognitively intact. Diagnoses included diabetes. Review of the resident's care plan in use at the time of survey, showed:-Focus: the resident has non-insulin dependent diabetes;-Goal: the resident will be free of all signs and symptoms of hypo/hyperglycemia (low or high blood sugar) such as sweating, trembling, thirst, fatigue, weakness, blurred vision through next review;-Interventions included: provide diet as ordered and conduct a comprehensive skin inspection weekly. Review of the resident's physician orders dated 11/4/25, showed a physician order for Humalog solution 100 unit/mL, inject 10 unit subcutaneously before meals for diabetes. The order failed to include perimeters for when staff should notify the MD. Review of the resident's MAR dated 11/3/25 through 11/30/25, showed a physician order for Humalog solution 100 unit/mL, inject 10 unit subcutaneously before meals for diabetes. Documentation showed on 11/25/25 at 12:00 P.M. the resident's blood sugar measured 57 (hypoglycemic) and the insulin was administered. Review of the resident's progress notes dated 11/25/25, showed no documentation the MD was notified of the residents low blood sugar. During an

interview on 12/19/25 at 1:30 P.M., the Director of Nursing (DON) said the nurse reported the resident's blood glucose level to her and told her he/she was holding the insulin and placed a call to the on-call through the exchange. The DON did not know if the on-call doctor called back or not. During an interview on 12/18/25 at 11:05 A.M, Licensed Practical Nurse (LPN) A said if a resident did not have a perimeter for his/her blood sugar he/she would notify the MD if the blood sugar was below 70 or above 350 and document it in the progress notes. During an interview on 12/18/25 at 11:35 A.M., LPN B said if a resident did not have perimeters for his/her blood sugar, he/she would notify the MD if the blood sugar was below 60 or above 400. If the MD was notified it would be documented in the progress notes. If a resident's blood sugar was low, he/she would hold the insulin, and give them orange juice or milk and follow up with the MD.

During an interview on 12/19/25 at 10:41 A.M., the Assistant Director of Nursing said when the nurse receives an order to check the blood sugar, they should also obtain an order for when the physician wants to be notified. If a resident did not have perimeters for their blood sugar, staff should notify the physician if

the blood sugar was below 70 or above 350. If the blood sugar was below 70, staff should not administer

the insulin, give them a snack, notify the physician and document it in the progress notes. When the nurse documents the insulin is held on the MAR, it will automatically generate a progress note. 4. During an

interview on 12/19/25 at 1:30 P.M. and at 3:37 P.M., the Administrator said she would expect staff to obtain perimeter orders for blood sugars when the order to check the blood sugar was obtained. Physician orders should be followed. 2688707

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

12/19/2025

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)

Federal health inspectors cited AVENIR AT MARK TWAIN in BRIDGETON, MO for a deficiency under regulatory tag F-F0684 during a complaint investigation conducted on 2025-12-19.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of AVENIR AT MARK TWAIN.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-01-15.