Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenir At Mark Twain during CMS and state inspections, most recent first.
A resident with multiple medical conditions experienced a fall after not locking their wheelchair. Nursing staff assessed the resident and notified the physician, but there was no documentation that the resident's representative was informed of the incident, contrary to facility protocol.
The facility did not consistently follow physician orders for blood glucose monitoring and failed to obtain or document parameters for physician notification for several residents with diabetes. In multiple cases, blood sugar checks were missed or out-of-range results were not reported to the physician as ordered, and staff practices varied when notification parameters were not specified.
A resident with multiple wounds and complex medical conditions was not thoroughly assessed or documented for surgical wounds upon admission and in subsequent weekly assessments, as required by facility policy. Key wounds were omitted from initial documentation, and wound tracking was delayed, with incomplete entries in the medical record and wound report. Staff interviews confirmed that expected assessment and documentation procedures were not followed.
A resident with multiple medical conditions and high risk for skin breakdown did not consistently receive ordered wound care, skin assessments, or use of heel protectors. Staff failed to complete and document weekly skin assessments, did not follow physician orders for compression wrap removal and wound dressing changes, and inconsistently recorded bathing and skin observations. The resident's skin was observed to be extremely dry, cracked, and bleeding, and staff interviews revealed confusion about treatment responsibilities and documentation.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
The facility did not consistently provide meals that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing food options. Residents were observed receiving food that did not meet their individual dietary requirements or preferences.
The facility did not provide required documentation showing that CNAs received at least 12 hours of annual inservice training, with missing or incomplete records for several staff. The DON and Administrator confirmed the expectation for annual education, but stated that previous records may have been removed by a former DON, resulting in insufficient documentation for regulatory compliance.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A resident with full code status was found unresponsive and staff initiated but discontinued CPR before EMS arrived, with a significant delay in contacting 911. Staff were unclear on code status procedures, and some were not CPR certified. The facility also failed to ensure a CPR-certified staff member was present on multiple night shifts, contributing to inadequate emergency response.
A resident with severe cognitive impairment and a full code status was found unresponsive and CPR was initiated by two LPNs but stopped before EMS arrived, contrary to facility policy and physician orders. The incident, which met the criteria for alleged neglect, was not reported to the State Survey Agency within the required two-hour timeframe. The Administrator acknowledged the reporting failure, citing a misunderstanding about who was responsible for notifying authorities.
Three residents did not receive care in line with professional standards after falls and hospital transfers, as staff failed to complete required progress notes, post-fall follow-up, and notifications to physicians and families. Care plans were not updated with new interventions, and fall prevention indicators were missing, with vital signs and neuro checks not consistently documented as per facility policy.
A facility failed to ensure lab services were obtained as ordered by a physician for a resident with multiple health issues, including heart failure and diabetes. Despite physician orders for several lab tests due to the resident's confusion and agitation, there was no documentation that these tests were conducted or that the resident refused them. Interviews revealed that the nurse responsible for entering the orders did not ensure they were completed, and the lab confirmed the orders were not processed, leading to a deficiency.
The facility failed to report an allegation of staff-to-resident verbal abuse to DHSS within the required two-hour time frame. A resident overheard a staff member threatening another resident with physical harm and reported it to the Social Worker, who did not report the incident due to being busy with a respiratory outbreak.
A facility failed to investigate an allegation of verbal abuse reported by a resident, despite the facility's policy requiring immediate action. The Social Worker did not initiate an investigation, and the staff involved were not questioned or suspended until the surveyor's intervention.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify a resident's representative after the resident experienced a fall. The resident, who was cognitively intact and had diagnoses including diabetes, hypertension, and end stage renal failure requiring dialysis, was found on the bathroom floor after not locking their wheelchair. The resident was assessed by nursing staff, found to be stable, alert, and oriented, with no pain or neurological changes. Documentation showed that the medical doctor was notified, but there was no evidence that the resident's representative was informed of the incident. Interviews with nursing staff and facility leadership confirmed that the expected protocol was to notify the physician and the resident's representative after a fall and to document these notifications in the progress notes. However, the administrator acknowledged that there was no documentation to show the family had been notified following the fall, indicating a failure to follow the facility's notification procedures.
Failure to Follow Physician Orders and Obtain Notification Parameters for Blood Glucose Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician orders related to blood glucose monitoring and physician notification for residents with diabetes. For one resident, there were multiple instances where blood sugar readings exceeded 300 mg/dl, as specified in the physician's sliding scale insulin order, but there was no documentation that the physician was notified as required. The Assistant Director of Nursing confirmed the lack of documentation for physician notification when blood sugars were outside the ordered parameters. Another resident had physician orders for blood glucose monitoring before each meal and a sliding scale for insulin administration, including instructions to notify the physician if blood sugar exceeded 350 mg/dl. However, documentation showed that blood glucose checks were not completed before supper, and there was no evidence that the physician order was changed to reflect this omission. The Assistant Director of Nursing stated that staff were expected to complete blood sugar checks before each meal as ordered. A third resident had an order for insulin administration before meals but lacked specific parameters for when to notify the physician of out-of-range blood glucose levels. On one occasion, the resident's blood sugar was documented as hypoglycemic at 57 mg/dl, and insulin was administered, but there was no documentation that the physician was notified. Interviews with nursing staff revealed inconsistent practices regarding when to notify the physician in the absence of specific parameters, and the Assistant Director of Nursing and Administrator both indicated that perimeter orders should be obtained and physician orders followed.
Failure to Accurately Assess and Document Surgical Wounds on Admission and Weekly
Penalty
Summary
The facility failed to thoroughly and accurately assess and document a resident's surgical wounds upon admission and then weekly, as required by facility policy. Specifically, the admission skin assessment did not include all wounds present, omitting the wound on the resident's left thumb and failing to provide a description of the wound on the left hand. Additionally, there was no admission note documented in the progress notes, and the care plan in use at the time of the survey did not reflect the wounds on the resident's left hand. The wound was not included in the facility's wound report for two consecutive weeks, and there was no wound documentation in the medical record until several weeks after admission. The resident involved had multiple diagnoses, including an open wound of the left hand, cellulitis of the left finger, abscess of the left hand, and diabetes, and required surgical wound care. Interviews with staff confirmed that wound assessments and documentation were expected to be completed on admission and weekly thereafter, including details such as location, size, drainage, odor, and surrounding tissue. However, these assessments and documentation were not completed as required, resulting in incomplete and delayed wound tracking for the resident.
Failure to Provide and Document Ordered Wound Care and Skin Assessments
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards for a resident with significant skin integrity issues. The staff did not consistently administer treatments as ordered for non-pressure wounds, failed to complete comprehensive skin assessments on a routine basis, and did not reassess the efficacy of treatments for ongoing skin problems. Documentation was incomplete or missing for weekly skin assessments, and there was a lack of follow-through on physician orders for wound care, application of creams, and use of heel protectors. Staff also failed to accurately document the administration of treatments, sometimes marking them as completed when they were not actually provided. The resident involved had multiple complex medical conditions, including paraplegia, morbid obesity, amputation, kidney failure, and osteomyelitis, and was at high risk for pressure ulcers and other skin breakdown. The resident was dependent on staff for mobility, hygiene, and wound care. Observations revealed that the resident's compression wraps were not being removed at night as required, heel protectors were not in place, and wound dressings were not changed according to schedule. The resident's skin was noted to be extremely dry, cracked, and in some areas bleeding, indicating that current treatments were not effective. Staff interviews confirmed a lack of clarity regarding treatment responsibilities and documentation procedures. Further review showed that shower and bed bath documentation was inconsistent, with missing or incomplete records of skin assessments during these activities. Staff were unsure about the use of certain lotions and the availability of bariatric shower chairs, despite one being present in the facility. The wound nurse and other staff acknowledged that skin assessments and treatments were not always completed as ordered, and that communication and documentation lapses contributed to the deficiencies. The facility's policies required regular skin assessments, accurate documentation, and adherence to physician orders, but these were not consistently followed.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options. This deficiency was identified based on observations that the facility did not consistently provide meals tailored to individual dietary needs and preferences, as required. The report notes that residents were not always offered food choices that considered their specific allergies or intolerances, nor were the meals always presented in an appealing manner.
Lack of Documentation for CNA Annual Inservice Training
Penalty
Summary
The facility failed to provide documentation of ongoing educational training for active Certified Nursing Aides (CNAs), as required by regulation, which mandates at least 12 hours of education per year. Record review showed that for four of six sampled active CNAs, there was insufficient or no documentation of completed inservice training for the required period. Specifically, some CNAs only had records of inservices from January 2025 onward, with no documentation for prior months, while others had no record of inservices for the past year from their hire date. The sample included 18 CNAs, and the facility census was 75.1. During interviews, the DON stated she was unable to locate annual education logs for four of the six sampled CNAs and did not have access to any annual training records completed before January 2025. The DON and Administrator both acknowledged that all CNAs are expected to receive 12 hours of ongoing education annually. It was reported that the previous DON may have taken inservice records and education documentation upon resigning, contributing to the lack of available documentation.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. No further details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Provide Timely and Appropriate CPR and Maintain CPR-Certified Staff
Penalty
Summary
The facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive and without a pulse. The resident had a full code status, as documented in the care plan and physician orders, and had expressed a clear desire to be resuscitated in the event of cardiac arrest. When the resident was discovered unresponsive, staff initiated CPR but discontinued efforts before emergency medical services (EMS) arrived. There was a significant delay in contacting EMS, with over an hour passing between the time the resident was found without a pulse and the time 911 was called. During this period, staff made phone calls to the family and physician, and CPR was not in progress when EMS arrived on the scene. Interviews with staff revealed confusion and lack of knowledge regarding code status determination and CPR procedures. Certified Nurse Aides (CNAs) on duty did not know how to access or determine a resident's code status, and some staff members involved in the event were not CPR certified. There were inconsistencies in staff accounts regarding who performed CPR, for how long, and whether appropriate equipment such as a backboard or ambu bag was used. Documentation and interviews indicated that CPR was stopped based on staff judgment rather than the arrival of EMS or a qualified medical professional pronouncing death, which was contrary to facility policy and standard practice. Additionally, a review of staffing records showed that the facility failed to ensure the presence of at least one CPR-certified staff member on 14 night shifts within a 30-day period, despite having a significant number of residents with full code status. The staffing coordinator was unaware of the requirement to have CPR-certified staff on each shift and did not maintain an updated list of staff CPR certifications. Human Resources did not provide the staffing coordinator with information on which staff were CPR certified, and there was no system in place to identify CPR-certified staff on staffing sheets. This lack of oversight contributed to the deficiency in providing timely and appropriate life-saving measures.
Failure to Timely Report Alleged Neglect After CPR Was Stopped Before EMS Arrival
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency. The incident involved a resident with severe cognitive impairment, lower extremity impairment, and diagnoses including COPD, emphysema, and dependence on supplemental oxygen. The resident was designated as a full code, with physician orders and care plan interventions specifying immediate initiation of CPR and calling 911 in the event of cardiac arrest. On the day of the incident, an LPN found the resident unresponsive and cold to the touch. The LPN, along with another nurse, attempted resuscitation per protocol but determined the resident had no heartbeat or oxygenation and ceased CPR before EMS arrived. The LPN notified the resident's family and physician, and subsequently called 911. Administration was notified early after the incident and assisted with contacts. However, CPR was not continued until EMS arrival, as required by facility policy and the resident's code status. The Administrator acknowledged during interviews that the incident should have been reported to the state as neglect within two hours, as stopping CPR prior to EMS arrival constituted a failure to follow physician orders and facility policy. The Administrator did not report the incident, stating that the Assistant Fire Chief indicated he would report it to the hotline. The facility's policies require immediate reporting of all alleged violations involving neglect, but this was not followed in this case.
Failure to Document and Follow Post-Fall Protocols and Notifications
Penalty
Summary
The facility failed to ensure that three residents received care in accordance with professional standards and facility policies following falls and hospital transfers. Specifically, staff did not complete required progress notes after residents experienced falls, were sent to the hospital, or returned from the hospital. There was also a lack of documentation regarding notifications to physicians and family members when these incidents occurred. Additionally, the facility did not consistently complete post-fall follow-up for 72 hours, which should have included progress notes per shift, vital signs monitoring, and neurological checks as outlined in facility protocols. For one resident, there was no documentation of the fall, notifications to the physician or emergency contact, or the resident being sent to or returning from the hospital. The care plan was not updated with appropriate interventions, and required fall prevention signage was missing from the resident's room. Vital signs were not monitored or documented for 72 hours post-fall. Another resident, who had severe cognitive impairment and was dependent on staff for most activities, also lacked documentation of family notification after a fall, and there was a missing neurological assessment entry. The care plan did not include interventions for the most recent fall. A third resident, identified as high risk for falls, had no progress notes regarding a fall or notification to the physician. There was also no documentation of post-fall follow-up notes for several shifts, and fall prevention indicators were not present in the resident's room. Across all three cases, the facility did not adhere to its own fall prevention, clinical protocol, and notification of changes policies, resulting in incomplete assessments, lack of care plan updates, and insufficient communication with medical providers and families.
Failure to Obtain Ordered Lab Services for Resident
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring that laboratory services were obtained as per physician orders for one resident. The resident, who was cognitively intact, had multiple diagnoses including heart failure, high blood pressure, diabetes, and COPD. On a specific date, the physician ordered several lab tests, including a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and others, due to the resident's confusion and agitation. However, there was no documentation that these labs were drawn, nor was there evidence that the resident refused the blood draw or that the family was notified of the new orders. The progress notes indicated attempts to obtain a urine sample through catheterization, but there was no success until several days later. Despite the physician's orders, the facility did not follow up with the lab to ensure the tests were conducted. The lab representative confirmed that the facility was responsible for entering lab orders into the computer system, and the phlebotomist would check for these orders during routine visits. However, the lab did not have records of the orders being entered for the specified period. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the nurse who obtained the order was responsible for entering it into the system. The DON acknowledged that the lab orders might have been overlooked or the resident might have refused the blood draw, but there was no documentation to confirm this. The lab admitted to not drawing the labs, and the facility did not have a system in place to verify the completion of lab orders, leading to the deficiency.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident verbal abuse to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. Resident #1 overheard a staff member threatening Resident #2 with physical harm if the resident pinched the staff member again. The incident occurred in the shared bathroom of the two residents. Resident #1 reported the incident to the Social Worker (SW) on 4/4/24, but the SW did not report the allegation to DHSS as required. The SW admitted to not reporting the incident due to being busy with a respiratory outbreak in the facility. Resident #1, who is able to make needs and wants known, has diagnoses including chronic pain, anxiety, and depressive disorder. Resident #2, who can make some needs and wants known, has diagnoses including diabetes, dementia with behavioral disturbances and agitation, depression, and muscle weakness, and requires moderate to total assistance with daily care needs. The Administrator confirmed that the SW should have reported the allegation to DHSS immediately upon receiving the report from Resident #1.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to follow its policy to investigate an allegation of verbal abuse between a Certified Nurse Aide (CNA) and a resident. The incident was reported by another resident who overheard the alleged abuse from a shared bathroom. Despite the report being made to the facility's Social Worker (SW), no investigation was initiated, and the allegation was not taken seriously. The SW admitted to not starting an investigation due to being busy with a respiratory outbreak in the facility. The resident who reported the incident described the staff member based on their voice and physical appearance. The description matched CNA A, who frequently cared for the resident involved in the alleged abuse. However, neither the Assistant Director of Nursing (ADON) nor the Director of Nursing (DON) were aware of the allegation until informed by the surveyor. The staff involved had not been interviewed or suspended as per the facility's abuse prohibition policy. Interviews with other staff members, including Licensed Practical Nurse (LPN) C and CNA B, revealed that they were not questioned about the incident, and no witness statements were taken. The Administrator confirmed that the SW should have started the investigation immediately upon receiving the report. The facility only began the investigation and took necessary actions after the surveyor's intervention.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bridgeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ssm Health Depaul Hospital - Anna House | 0.4 mi | — | 1 | 0 |
| Parkwood Skilled Nursing And Rehabilitation Center | 0.6 mi | — | 7 | 0 |
| Stonebridge Maryland Heights | 1.1 mi | — | 2 | 0 |
| Life Care Center Of Bridgeton | 1.5 mi | — | 0 | 0 |
| Nhc Healthcare, Maryland Heights | 1.6 mi | — | 1 | 0 |
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