Avenir at Mark Twain

In the surveyor’s words

From the most serious findings on record at Avenir at Mark Twain, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 19, 2024

  Based on observation, interview and record review, the facility failed to ensure the resident environment remained free from hazards and residents received supervision per the facility's smoking protocol and individual resident smoking assessments when five residents were left unattended in the outside courtyard without staff available to let them back in for approximately 30 minutes during freezing weather conditions, with a temperature of 22 degrees Fahrenheit (F) and wind speeds of nine miles per hour (mph) (Residents #69, #58, #65, #63 and #68). One resident (Resident #69) required supervision at all times for safety. […]

• Immediate jeopardy, isolatedF689Jun 22, 2026

  Based on interview and record review, the facility failed to ensure residents received adequate assistance to prevent accidents when Certified Nurse Aide (CNA) F provided improper transfers to two residents (Residents #3 and #4) resulting in injury. Resident #3 was identified by the facility as requiring a Hoyer lift for transfers. On 05/16/26, CNA F transferred the resident by picking up the resident without a lift, a gait belt, or another employee to assist. The resident's foot got caught, resulting in a fractured right tibia (shin bone) and fibula (calf bone). CNA F was suspended, re-educated on the facility's transfer policies, and returned to work. Resident #4 was identified by the facility as requiring two staff to assist with transfers. […]

• Immediate jeopardy, isolatedF678Jan 21, 2025

  Based on interview and record review, the facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one (Resident #1) of three sampled residents, who was found by staff without a pulse. Staff started CPR on a resident with full code orders but stopped before Emergency Medical Services (EMS) arrived. The Certified Nurse Aides (CNAs) on duty said they did not know how to determine code status. EMS was not notified timely, the resident was discovered without pulse at 5:10 A.M. and EMS was not contacted until 6:14 A.M. The resident expired. […]

• Immediate jeopardy, isolatedF678Jan 18, 2022

  Based on interview and record review, the facility failed to ensure agency staff performed Cardiopulmonary Resuscitation (CPR, life sustaining measure in the event the heart stops beating) for a resident (Resident #1) with a full code (in the event a resident is found without signs of life (respirations, pulse) CPR will be initiated) order. The resident was found unresponsive by the certified nursing assistant (CNA) who notified the agency nurse. The agency nurse thought since the resident had been admitted to hospice, his/her code status changed to do not resuscitate (DNR, no attempts at resuscitation will be made), but failed to check the resident's chart to verify the order. The resident had been admitted to receive hospice services, but his/her code status remained a full code. […]

• No harm, potential for more than minimal, patternF550Aug 20, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner affecting 5 of 18 sampled residents (Residents #1, #58, #64, #28 and #5). The census was 75. Review of the facility's resident's rights policy, undated, showed:-Employees shall treat all residents with kindness, respect, and dignity;-Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity;-Respect: Treat others as you want to be treated-every person matters. 1. […]