Bluebird Wellness and Rehab: Aide Left Resident Alone, Fall - MO
The fall happened between 4:00 and 5:00 A.M. The resident was sent to the hospital for evaluation. When they returned, they told a registered nurse that there had been only one aide in the room. The aide had rolled them onto their side, then left.
The care plan required two-person assistance for all personal care, hygiene, and turning. Every CNA on the floor had access to that information through the computer system, the ADL sheet, or the Kardex. The resident required a mechanical lift for transfers and was on a low air loss mattress, conditions that the Assistant Director of Nursing said should have triggered two-person assist on their own.
The Director of Nursing said the nurse who assessed the resident after the fall noted no injuries, but the resident asked to go to the hospital. Neurological checks were completed there. The CNA was terminated. Staff were in-serviced on gathering supplies before entering a room and on the two-person requirement. The administrator and Director of Nursing held a care plan meeting with the family.
CNA F, interviewed by inspectors on October 9, confirmed the resident could move only their head and neck and needed two-person assist. Certified Medication Technician E said the resident required two to three people for care.
The Director of Nursing told inspectors staff knew which residents required two-person assistance. They could look it up, or they could ask the nurse. The information was there.
The resident had asked to go to the hospital. A small laceration on their head, and a dresser they should never have been close enough to hit.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 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 between 4:00 and 5:00 A.M.
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.