Bluebird Wellness: Resident Left Alone, Falls From Bed - MO
The fall happened on August 9, 2025, at Bluebird Wellness and Rehabilitation. Federal inspectors documented the incident during a complaint inspection on October 9.
The resident could move only their head and neck. Their care plan required two-person assistance for personal care, hygiene, and turning and positioning. The resident was also noted to sometimes jerk unexpectedly. They were on a low air loss mattress, which the facility's Assistant Director of Nursing later told inspectors made the situation worse: the resident was top heavy, the CNA had crossed their legs while rolling them onto their side, and when the aide stepped out, the resident went over the edge.
The resident hit their head on the dresser. There was a small laceration. The resident complained of neck pain and pain at the back of the head. They were sent to the hospital to be evaluated.
The CNA who provided the care was working alone. The resident required two people.
When the resident returned from the hospital, they told the day shift nurse what had happened: the aide had rolled them, then left the room. The resident told the same story to the evening nurse, LPN D, who worked that night. LPN D told inspectors she had assumed the CNA was caring for the resident with a second person. She could not recall the CNA's name. She noted the CNA was no longer at the facility.
RN B, interviewed the morning of the inspection, said staff knew which residents needed two-person assistance from shift report, from the ADL sheet, or from the Kardex. The information was available. "Staff should take their supplies with them when they enter the room," RN B said.
The ADON described the same expectation. She told inspectors she would expect two-person assistance for any resident on a low air loss mattress or requiring a mechanical lift, regardless of what else the care plan said. Staff should gather everything before going in. They did not.
The Director of Nursing said the nurse who assessed the resident after the fall noted no injuries. The resident asked to go to the hospital anyway and was sent. Neurological checks were completed. The CNA was terminated. Staff were in-serviced on collecting supplies before entering a room and on keeping two staff present for dependent residents. The Administrator and Director of Nursing held a care plan meeting with the family.
CNA F, interviewed the day of the inspection, was direct about what the resident needed: the resident could move only their head and neck and required two-person assistance. CMT E said the same, adding that if staff were ever uncertain about a resident's care needs, they were expected to ask the nurse.
The Administrator told inspectors she expected staff to follow the facility's policies and procedures. The care plan, she said, should have shown how many staff were required.
It did. Nobody followed it.
The resident was on a specialized pressure mattress in the early hours of the morning, unable to move most of their body, being cared for by a single aide who then walked out of the room. When the aide left, there was no one there to stop what happened next.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bluebird Wellness and Rehabilitation from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
BLUEBIRD WELLNESS AND REHABILITATION in SAINT LOUIS, MO was cited for violations during a health inspection on October 9, 2025.
The fall happened on August 9, 2025, at Bluebird Wellness and Rehabilitation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.