Bluebird Wellness And Rehabilitation
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
waist height). There was no immediate injury, he/she complained of neck and back of the head pain.
He/She was given pain medication. The resident was sent to the hospital. LPN D could not recall the name of the CNA but said the CNA was no longer at the facility. After the resident returned from the hospital, he/she told the day nurse the CNA left out of the room and that's when he/she fell. The day shift nurse reported it to management. LPN D worked the evening shift on 8/9/25 and the resident also told him/her the same thing. The resident required two person assist for ADL care. LPN D assumed the CNA was caring for
the resident by him/herself. 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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If continuation sheet
BLUEBIRD WELLNESS AND REHABILITATION in SAINT LOUIS, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.