Inspection Reports for
Bluebird Wellness and Rehabilitation

The complaint investigation was substantiated. The resident fell on 2025-08-09 after being left unattended by a CNA who left the room to get supplies. The resident required two-person assistance but was cared for by one staff member alone. The resident sustained a small laceration and contusion and was sent to the hospital for evaluation.

The facility failed to ensure adequate supervision and assistance for a resident requiring two-person assistance, resulting in the resident falling from bed and sustaining minor injuries. Staff were in-serviced, the responsible CNA was terminated, and a care plan meeting was held with the family.

The facility was found deficient in honoring a resident's Durable Power of Attorney for financial matters, incorporating PASARR recommendations into care plans, providing wound care and weight monitoring per orders, documenting and managing a resident fall appropriately, ensuring safe smoking practices, completing dialysis assessments, timely pharmacist medication review responses, proper medication storage and labeling, and accommodating resident food preferences.

The facility was found deficient in honoring a resident's Durable Power of Attorney regarding financial matters, incorporating PASARR Level II recommendations into care plans, providing appropriate post-fall care and documentation, ensuring safe smoking practices, and completing dialysis pre/post assessments as ordered.

The facility failed to provide medication per physician's order, failed to ensure timely laboratory services for residents, and did not follow proper infection control procedures during blood sugar testing and insulin administration. Deficiencies were noted for multiple residents with minimal harm and few residents affected.

The facility failed to provide services meeting professional standards for one resident related to medication administration without a physician's order, failed to provide or obtain laboratory services for one resident, and failed to ensure staff used acceptable infection control procedures during blood sugar testing and insulin administration for one resident.

Two deficiencies were identified: failure to protect residents from wrongful use of their belongings or money, and failure to provide appropriate pressure ulcer care and prevent new ulcers from developing. Both deficiencies affected a few residents and had severity levels of minimal harm and immediate jeopardy respectively.

The facility failed to meet professional standards in multiple areas including wound care, medication administration, nursing staffing, respiratory care, and medical record documentation. Several residents experienced delayed or inadequate care, medication errors, and incomplete medical records.

The facility failed to ensure treatments for pressure ulcers were completed as ordered for three residents, had a medication error rate exceeding 5%, and did not accurately document treatment administration records for pressure ulcer care and pain medication for certain residents.

The facility failed to ensure professional standards of care in multiple areas including failure to apply compression suits as ordered, delayed wound assessments and treatments, inadequate respiratory assessments and documentation for tracheostomy residents, insufficient licensed nursing staff on the rehab floor leading to missed medications and treatments, and medication administration errors with failure to document and notify physicians and representatives.

The facility was found deficient in multiple areas including resident rights and dignity, financial management of resident funds, notification of abnormal blood sugar levels, grievance policy adherence, employee screening, PASARR screening, care planning, wound care, restorative therapy, medication administration, food safety, and bed rail safety assessments.

The facility was found deficient in multiple areas including failure to notify physicians of abnormal blood sugar levels, failure to maintain grievance logs for three years, expired IV therapy supplies in medication rooms, inadequate assistance with activities of daily living during meals and personal care, failure to provide wound care per standards, and medication administration errors involving nicotine patches.

The investigation was complaint-driven, focusing on medication administration errors related to respiratory treatments for two residents. The complaint was substantiated with findings of missed treatments and inaccurate documentation.

The facility failed to administer ordered nebulizer treatments to Resident #7 and inhaler treatments to Resident #11 as prescribed. Staff incorrectly documented medication administration when treatments were not given, and the emergency medication supply was not accessed when medications were unavailable.

The facility failed to provide a homelike dining environment for residents in the Rehabilitation Building by keeping the dining room closed since COVID, resulting in residents eating all meals in their rooms with frequent use of plastic utensils. Dietary staffing was insufficient to open the Rehabilitation dining room. Medication administration errors occurred, including failure to administer ordered nebulizer and inhaler treatments. Food was often served at inappropriate temperatures, and the facility did not provide clear alternative meal options to residents.

The facility failed to ensure proper handling of a deceased resident's body according to prearranged funeral plans and lacked documentation of funeral preferences. Additional deficiencies were cited related to dignity/privacy, safe environment, medication administration, dietary support, and food service.

The complaint investigation substantiated failures in honoring a resident's prearranged funeral plans, medication administration errors for residents with respiratory infections, inadequate dining environment and utensils, insufficient dietary staffing, improper food temperatures, and lack of alternative meal options.

The facility failed to release a deceased resident's body to the correct funeral home per prearranged plans, provided inadequate dining conditions including closed dining room and plastic utensils, failed to administer ordered respiratory medications to residents, lacked sufficient dietary staff to open the rehabilitation dining room, served food at improper temperatures, and did not provide residents with clear alternative meal options.

The investigation was triggered by complaints of missing money and debit card misappropriation involving four residents. The facility's investigations were incomplete, lacking interviews from all relevant staff and proper documentation. The resident with the missing debit card had an unauthorized $125 charge. Other residents reported missing cash and personal items. The facility did not identify perpetrators or fully investigate all shifts and non-nursing staff.

The facility failed to conduct thorough investigations into missing resident money and debit cards, did not ensure proper wound care orders and documentation following a podiatry procedure, and failed to maintain sanitary food handling and temperature recording practices in the dietary department.

The facility failed to ensure one resident was free from abuse when CNAs confronted and struck the resident multiple times. The administrator was notified of the Immediate Jeopardy on 3/23/23, and the facility took corrective actions including staff awareness and policy review.

The complaint investigation was substantiated. The incident involved physical abuse by CNA X against Resident #85 on 3/19/2023. The facility and police intervened promptly. The resident was emotionally and physically affected. The facility took corrective actions including staff inservice on abuse policies and removal of the involved CNAs.

The facility failed to protect a resident from abuse when two CNAs confronted and yelled at the resident about missing money and one CNA struck the resident in the face. The Staffing Coordinator witnessed the incident but left the resident unsupervised with the CNAs. The police were called, and CNA X was arrested. The resident sustained a red, watery eye and was emotionally distressed.

The complaint investigation was substantiated as the facility failed to report allegations of abuse within required timeframes and did not secure cleaning products, leading to a resident ingesting a hazardous substance. The resident was transferred to the hospital but was not harmed by the deficient practices.

The facility failed to report alleged violations of abuse and neglect within the required timeframes. Additionally, the facility did not ensure cleaning products were properly secured, leading to a resident ingesting Pine-Sol. The facility's policies and procedures regarding reporting and safety oversight were not followed.

The complaint involved an allegation by a resident's family member that the resident had been hit in the face, resulting in a black eye and broken nose. The facility failed to report this allegation to DHSS as required. The police investigated and found no evidence of bruising or broken nose. The resident was unable to communicate about the incident. The family member did not provide specific details about the alleged perpetrator. The allegation was not substantiated by the investigation.

The facility failed to report an allegation of abuse to the Department of Health and Senior Services within the required timeframe and failed to ensure hazardous cleaning products were properly secured, resulting in a resident consuming Pine-Sol. Both incidents involved minimal harm with few residents affected.

The facility failed to ensure residents were free from physical abuse when a staff member was observed wrestling a resident and causing bruises and abrasions. The facility implemented corrective actions including staff education, termination of the involved employee, and notification of authorities.

The facility failed to ensure food was palatable, served at safe and appetizing temperatures, and consistent with posted menus. Multiple residents and staff reported and were observed receiving cold, unappetizing meals, with issues including missing condiments, incorrect meal portions, and poor food quality.

The facility failed to meet several Life Safety Code requirements including maintaining clear emergency exits, proper signage on delayed-egress doors, self-closing doors to hazardous areas, prohibition of combustible decorations, and proper storage and maintenance of electrical equipment and oxygen cylinders. These deficiencies had the potential to affect residents and staff in multiple smoke compartments and areas of the facility.

The facility was found deficient in multiple areas including failure to honor resident rights and dignity, inadequate pain management, failure to promote resident self-determination, untimely completion of third party liability forms for expired residents, failure to post abuse hotline information, failure to notify family of resident fall and lab results, failure to return resident personal possessions, incomplete employee background checks, inadequate investigation of abuse allegations, incomplete and inaccurate care plans, medication administration errors, failure to provide necessary assistance with activities of daily living, unsafe medication storage and labeling, lack of routine bed rail inspections, inadequate privacy in semi-private rooms, and ineffective pest control.

The complaint investigation was substantiated with findings of neglect, abuse, medication errors, failure to respect resident rights, and inadequate care planning and environment safety.

The investigation found multiple deficiencies including failure to respect resident rights, inadequate abuse and neglect policies, medication errors, improper care planning, and failure to ensure a safe and comfortable environment for residents.

The facility failed to provide adequate sprinkler coverage for an outside overhang, maintain signage for fire department connection valves, maintain smoke barriers with required fire resistance, and properly dispose of smoking materials in designated smoking areas. These deficiencies had the potential to affect residents and occupants in multiple areas of the facility.

The facility was found to have multiple deficiencies including failure to provide reasonable accommodations for residents, failure to ensure residents were free from abuse and neglect, inadequate notification and documentation of room changes, failure to follow proper medication administration policies, and food safety violations. The facility submitted a plan of correction addressing these issues.

The facility failed to timely provide or obtain required specialized rehabilitative services from an outside resource for one sampled resident. The deficiency was related to delays in initiating physical and occupational therapy services as ordered by the physician.

The complaint involved an allegation that a certified nursing assistant (CNA) abused Resident #11 by hitting him/her. The investigation included interviews with staff and review of medical records. The police investigated and found the abuse allegation unwarranted. The facility concluded the incident was unsubstantiated.

The facility failed to prevent further potential abuse during the investigation by not ensuring the accused employee was immediately removed from resident care. The abuse allegation was ultimately found to be unsubstantiated after investigation and interviews.

The facility failed to provide emergency preparedness training to staff on an annual basis and did not maintain sprinkler heads free of debris and obstructions. Several sprinkler heads were improperly installed or corroded, smoke dampers were not maintained in working order, smoking areas were not properly managed, and electrical receptacles and equipment were not adequately tested or maintained.

The report details multiple deficiencies identified during the survey, including issues with resident rights, care planning, medication management, nursing services, food safety, and infection control. The facility submitted corrective actions to address each cited deficiency.

The complaint investigation was substantiated. The violation was determined to be at an imminent danger Class I level for the elopement incident.

The facility failed to provide adequate supervision and protective oversight for a resident at risk for elopement, resulting in the resident leaving the building without staff knowledge and being missing for an undetermined amount of time. The facility did not follow their policy and procedure for locating the resident and notifying authorities. The facility also failed to maintain sufficient nursing staff to assure resident safety and care.

The complaint investigation was substantiated as the facility failed to follow policies related to abuse, neglect, and misappropriation, and failed to follow physician orders and prevent accidents.

The facility failed to follow its policy for reporting injuries of unknown origin and did not notify the Department of Health and Senior Services timely. The facility also failed to follow physician orders for glucose readings and did not adequately prevent accidents or monitor bruising and injuries of unknown origin.

The complaint investigation was substantiated with findings of neglect, abuse, failure to provide adequate care, and failure to follow required policies and procedures. Resident #111 was not given choice of showers, Resident #73 was exposed to smoking against policy, and multiple residents experienced inadequate care and documentation.

The facility was found to have multiple deficiencies related to resident care, including failure to ensure residents' rights, inadequate staff training, improper medication administration, and failure to follow abuse and neglect policies. Several residents were affected by these deficiencies.

The facility failed to meet the applicable provisions of the 2012 Life Safety Code due to the fire alarm and sprinkler systems being out of service for more than four hours. The facility lacked adequate fire watch policies and procedures during these outages.