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Complaint Investigation

Bluebird Wellness And Rehabilitation

October 9, 2025 · Saint Louis, MO · 9350 Green Park Road
Citations 1
CMS Rating 1/5
Beds 188
Provider ID 265703
Healthcare Facility
Bluebird Wellness And Rehabilitation
Saint Louis, MO  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

BLUEBIRD WELLNESS AND REHABILITATION in SAINT LOUIS, MO — inspection on October 9, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689
Quality of Life and Care Deficiencies

During an interview on 10/9/25 at 2:00 P.M., Assistant Director of Nursing (ADON) said the resident told them the CNA was doing care by him/herself and the CNA flipped his/her legs over (crossed legs).

The aide forgot some items and left to obtain them.

The resident was on a low air loss mattress, and he/she was top heavy and fell off the edge of the bed. He/She hit his/her head on the dresser and had a small laceration.

The resident was sent to the hospital to be evaluated.

She would expect staff to use two person assist for any resident who used a low air loss mattress and/or mechanical lift for transfers.

Staff should gather all supplies before going into the room.

Staff were in-serviced on keeping supplies in the residents' room and using two staff for care.

During an interview on 10/9/25 at 3:45 P.M., The Director of Nursing (DON) said staff knew which residents required two-person assistance by looking in the computer or they could ask the nurse.

The DON heard the CNA left out of the room to get supplies, the resident was left unattended and fell.

The nurse assessed the resident; no injuries noted. He/She requested to go to the hospital and was sent out.

Neurological checks were completed.

Staff were in-serviced, the CNA was terminated, and the Administrator and DON had a care plan meeting with the family.

The DON expected staff to obtain all supplies before going into the room to provide care, staff should not leave residents unattended, and quadriplegia residents should have two-person assistance.

During an interview on 8/9/25 at 11:30 A.M., Certified Medication Technician (CMT) E said the resident required two-to-three-person assistance. If he/she did not know what type of care a resident needed he/she would ask the nurse.

During an interview on 10/9/25 at 12:25 P.M., CNA F said the resident was only able to move his/her head and neck and needed two person assist.

During an interview on 10/9/25 at 6:00 P.M., the Administrator said she would expect staff to use two-person assistance for care for residents who are dependent on staff for care and used a low air loss mattress, the care plan should have shown the number of staff required to provide assistance.

Staff should make sure they have their supplies when they go into a resident's room.

Staff are expected to follow the facility's policy and procedures.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAINT LOUIS, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BLUEBIRD WELLNESS AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.