Bluebird Wellness And Rehabilitation
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
During an interview on 10/9/25 at 11:03 A.M., RN B said if a resident's care plan showed the resident was dependent for ADL Care, that meant the resident required two-person assistance. CNAs knew which residents required two persons assistance from report, or they could look at the ADL sheet or the Kardex.
The resident required two-person assistance for providing personal care/hygiene and for turning and positioning.
Sometimes the resident would jerk.
The fall occurred between 4:00 and 5:00 A.M.
When the resident returned from the hospital, he/she told RN B there was only one aide in the room, the aide rolled him/her onto his/her side and left out of the room to go get something and he/she fell. RN B said staff should take their supplies with them when they enter the room.
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. 2585289
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