Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country View Nursing during CMS and state inspections, most recent first.
A cognitively intact resident who required one-person assistance with ADLs reported that an agency CNA refused needed help at bedtime, told the resident to perform tasks independently, and then slapped the resident in the face with a soiled brief while providing rough care that caused pain and pinching. The CNA spoke in a harsh, rude tone and falsely gave another staff member’s name when asked to identify themselves. The resident’s cognitively intact roommate corroborated hearing the resident complain of pinching, hearing the CNA deny it, and seeing the CNA repeatedly smack the resident’s face with gloves while speaking in a mean, disrespectful manner, all occurring without the privacy curtain drawn. Another CNA later reported the resident’s allegation to the charge nurse, and facility records linked the conduct to an agency CNA assigned to that hall.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
A resident with significant mobility impairments was transported in a facility van using only two functional wheelchair straps, resulting in the wheelchair tipping over and the resident sustaining a head injury. Multiple residents reported feeling unsafe during van transport due to loose or missing straps, and staff lacked training on proper securing procedures. Despite repeated concerns raised in council meetings, maintenance issues with the van's straps and seatbelts were not addressed or documented, and no policy or training was provided for transport staff.
The facility did not have a full-time, licensed administrator physically present as required, with the acting administrator not holding a current license and the displayed license belonging to another administrator who was only present once a week. Staff interviews confirmed gaps in administrator coverage, and the facility lacked a policy outlining administrator duties.
Two residents did not receive wound care as ordered due to failures in transcribing and documenting physician and wound care clinic orders, including missing or incomplete entries for dressing changes and ace wrap applications. Additionally, one resident missed multiple wound care clinic appointments because transportation was not provided. LPNs reported that orders were sometimes missed or not fully entered, and there was no consistent review process for faxed orders. The DON expected staff to follow and document all treatment orders as directed.
The facility failed to provide dignified care when staff did not promptly answer call lights, causing two residents to experience incontinence. Despite being cognitively intact, the residents had to wait 35 minutes for assistance, with one becoming incontinent. Observations showed multiple call lights activated, with staff present but not responding promptly. The facility's policy required all staff, including temporary agency staff, to answer call lights, but this was not adhered to.
A facility failed to provide a resident's POA with medical records within 24 hours of a request. The POA initially asked an LPN for access but was only given physician orders. An email request was sent to the Social Services Director, who forwarded it to medical records staff. However, the staff was unaware of the request, leading to a delay in providing the records.
The facility did not notify the POAs of two residents involved in an altercation, despite its policy requiring such notification. One resident with dementia slapped another with schizoaffective disorder, and although the incident was reported and the residents were separated, the POAs were not informed. Interviews revealed that the POAs were unaware of the incident, highlighting a deficiency in the facility's notification procedures.
A resident with a history of stroke and recent surgery did not receive prescribed anticoagulant medication due to incorrect discontinuation of the order by an LPN. Additionally, the facility failed to coordinate follow-up appointments as per hospital discharge orders. The Medical Records/Transportation Staff were not informed of the need for transportation, and the discharge orders were not scanned into the electronic medical record.
The facility failed to treat residents with dignity and respect, as evidenced by rough handling and dismissive comments from staff, refusal to assist a resident due to their MRSA diagnosis, and repeated turning off of a call light without providing help. These incidents involved residents who were cognitively intact and had specific care needs, highlighting a lack of proper communication and support from staff.
Failure to Protect Resident From Physical and Verbal Abuse by Agency CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from staff abuse, as required by its Abuse, Prevention and Prohibition Policy. The resident, who was responsible for self and had diagnoses including unspecified dementia, low back pain, neuralgia and neuritis, and osteoarthritis, required assistance with ADLs such as undergarment changes, peri-care, dressing, transfers, and toileting. On the evening in question, the resident requested help from an agency CNA at bedtime to change an incontinent brief and get ready for bed. The CNA told the resident to do it independently and insisted the resident did not need help, despite the resident’s care plan indicating a need for one-person assistance with these tasks. During this interaction, the CNA took the resident’s soiled brief and slapped the resident in the face with it. The resident reported that the CNA was physically rough, jerked the resident around while assisting with clothing and brief changes, and pulled the brief up in a way that pinched and caused shoulder pain. The CNA spoke in a rude, harsh tone, repeatedly telling the resident to perform tasks independently and denying that pinching was occurring when the resident protested. The resident stated this treatment made him or her angry and feel unsafe. The resident also reported hitting a hand on the door when coming out of the bathroom and described the CNA as an agency staff member without a name tag who falsely gave another staff member’s name when asked to identify themselves. The resident’s roommate, who was also cognitively intact, corroborated key aspects of the abusive interaction. The roommate reported hearing the resident tell the CNA to stop pinching and hearing the CNA deny pinching while stating they were just trying to provide care. The roommate observed the CNA smack the resident back and forth in the face several times with gloves in the resident’s room, noted that the privacy curtain was not pulled, and described the CNA’s tone as harsh, rude, disrespectful, and mean. The roommate stated the CNA told the resident they would not help with getting ready for bed and that the resident could do it alone. The roommate felt uncomfortable witnessing the interaction and confirmed that the resident later reported the incident to staff. Facility records showed that the allegation was reported by another CNA after the resident described feeling unwell due to the way the aide had treated them, and the facility’s investigation identified the agency CNA assigned to that hall as the alleged perpetrator of physical abuse.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Secure Wheelchair Residents During Van Transport Due to Faulty Straps and Lack of Staff Training
Penalty
Summary
The facility failed to ensure that residents who required wheelchair transport were safely and properly secured during van transportation. On multiple occasions, staff transported residents using a facility van with malfunctioning wheelchair straps, with only two out of four straps functional. During one incident, a resident with end stage renal disease, hemiplegia, and impaired mobility was transported to and from dialysis with only two straps securing the wheelchair. On the return trip, one strap came loose while navigating a roundabout, causing the resident's wheelchair to tip backward, resulting in the resident hitting their head and sliding to the floor of the van. The resident sustained a bump and scratch to the head and later experienced a sudden loss of vision, prompting a hospital evaluation. Prior to this incident, residents had repeatedly voiced concerns about the condition of the van seatbelts and the lack of proper securing during transport in Resident Council meetings. Documentation showed that these concerns were either not addressed, inadequately documented, or not communicated back to residents. Maintenance logs did not reflect any work orders or repairs for the van straps or seatbelts, and there was no evidence of routine checks or a manufacturer's manual for the equipment. Staff interviews revealed a lack of training on how to properly secure wheelchairs in the van, and some staff believed that certain types of wheelchairs did not require strapping. Additionally, unlicensed staff were involved in transporting and assisting residents after accidents occurred. Multiple residents reported feeling unsafe during van transport, with some stating they had to hold onto bars or seats to prevent movement due to loose or missing straps. Staff acknowledged ongoing issues with the straps, but no formal maintenance requests were made, as it was assumed that everyone was aware of the problem. The facility did not provide a policy or training for staff responsible for transporting residents, and there was confusion among staff regarding responsibility for assessing and maintaining the safety of the van's securing mechanisms.
Failure to Maintain Full-Time Licensed Administrator
Penalty
Summary
The facility failed to comply with state laws by not designating a full-time, licensed administrator who was employed in the facility and serving in that capacity. Multiple interviews revealed that there was a period when the facility was without an administrator for at least one week, and the individual acting as administrator had not applied for a temporary emergency license. The license displayed in the facility belonged to another administrator who was only present in the building once a week, rather than serving full-time as required. Staff interviews confirmed uncertainty about when the licensed administrator was last physically present in the facility. Additionally, the facility did not have a policy regarding the administrator or their duties. The Regional Director of Clinical Operations acknowledged that the acting administrator was hired for the role, but the license displayed was not current for the acting administrator. The census at the time was 42 residents, and the lack of a full-time, licensed administrator had the potential to affect all residents in the facility.
Failure to Complete and Document Physician Wound Care Orders and Ensure Clinic Access
Penalty
Summary
The facility failed to follow professional standards of practice by not completing physician orders for wound care as prescribed for two residents. For one resident with a Stage III pressure ulcer on the left heel, multiple orders from the contracted wound care company, including the application of ace wraps from toes to knee and specific dressing changes, were not transcribed onto the physician order sheet (POS) or the Treatment Administration Record (TAR). As a result, these treatments were not documented as completed, and previous orders were not discontinued when new orders were received, leading to overlapping and potentially conflicting wound care treatments. Another resident with multiple pressure ulcers, including a Stage III sacral ulcer, did not have updated wound care clinic orders entered into the POS or documented on the TAR. Orders for wound cleansing, dressing applications, and wound vac management were either missing or incomplete in the records. On several occasions, staff failed to document that wound care treatments were performed as ordered, and there were discrepancies between the wound care clinic's recommendations and what was recorded in the facility's records. Additionally, the facility failed to ensure that this resident had transportation to scheduled wound care clinic appointments, resulting in missed visits. Interviews with nursing staff revealed that orders from the wound care clinic were sometimes missed or not fully transcribed into the POS, and there was no clear process to ensure that all faxed orders were reviewed and entered correctly. The Director of Nursing confirmed that documentation was expected to match the wound care company's orders and that staff were expected to follow treatment orders as directed.
Delayed Response to Call Lights Leads to Resident Incontinence
Penalty
Summary
The facility failed to provide care in a dignified and respectful manner for two residents when staff did not answer call lights promptly, resulting in incontinence and residents waiting in soiled briefs. Resident #3, who was cognitively intact and required maximal assistance with toileting hygiene, reported having to wait a long time for staff to respond to his/her call light, which led to incontinence. Similarly, Resident #4, also cognitively intact and requiring supervision with toileting hygiene, experienced delays in staff response, resulting in wetting his/her pants before reaching the restroom. Observations on the day of the incident showed multiple call lights activated across different halls, with staff members, including an LPN and a CMT, present but not responding promptly. Both residents had to wait 35 minutes for assistance, during which Resident #3 became incontinent. Interviews with the ADON and the Administrator revealed that all staff, including temporary agency staff, were expected to answer call lights promptly, but this expectation was not met, leading to the deficiency.
Failure to Provide Medical Records to Resident's POA
Penalty
Summary
The facility failed to provide a resident's power of attorney (POA) with a copy of the resident's medical records within 24 hours of a written request. The resident, who was admitted to the facility from the hospital and later discharged, had their POA request access to the medical records. The POA initially asked an LPN to view the records but was informed that they were on the computer and was only provided with a copy of the physician orders. Subsequently, the POA emailed the Social Services Director requesting the records, who then forwarded the request to the medical records staff. However, the Medical Records/Transportation Staff stated that she was unaware of the request and had not received any paperwork regarding it. She mentioned that if she had received the request, she would have provided the records within 24 hours. The Administrator later noted that the Social Services Director should have followed up to ensure the medical records staff received the request. This lack of communication and follow-up resulted in the failure to provide the requested medical records in a timely manner.
Failure to Notify POAs After Resident Altercation
Penalty
Summary
The facility failed to adhere to its policy of notifying the power of attorney (POA) for two residents involved in a resident-to-resident altercation. The incident involved a resident with dementia and anxiety disorder, who slapped another resident with schizoaffective disorder and bipolar depression. The altercation was reported to the Social Services Director three days after it occurred, and both residents were separated immediately. However, the POAs for both residents were not informed about the incident, contrary to the facility's policy that mandates notification of significant changes in a resident's status, including altercations. Interviews with the residents' POAs revealed that neither was contacted by the facility regarding the altercation. One POA learned about the incident through a text from the resident, while the other was unaware until the interview. The facility's administrator was under the impression that the POAs had been contacted, as per the staff's report, but this was not the case. The failure to notify the POAs represents a deficiency in following the facility's policy for significant condition change and notification.
Failure to Follow Hospital Discharge Orders and Medication Administration
Penalty
Summary
The facility failed to adhere to hospital discharge orders for a resident who had undergone surgery on the digestive system and had a history of stroke-related hemiplegia and hemiparesis. The resident was prescribed Eliquis, an anticoagulant, to be taken twice daily. However, the medication was only administered once on the day of admission, and the order was incorrectly discontinued the following day without any documented physician directive to do so. The resident did not receive the prescribed Eliquis from July 31 to August 11, when it was resumed at the resident's request. Additionally, the facility did not coordinate the resident's follow-up appointments with the primary care physician, gastroenterologist, and surgeon as outlined in the hospital discharge orders. The Licensed Practical Nurse (LPN) responsible for transcribing the orders claimed to have seen instructions to hold the Eliquis indefinitely, although no such documentation was found in the medical records. The LPN also failed to ensure that the discharge orders were properly communicated to the Medical Records/Transportation Staff for scheduling necessary follow-up appointments. The Medical Records/Transportation Staff did not schedule transportation for the resident's follow-up appointments, as they were not informed of the need for such arrangements. The hospital discharge orders were not scanned into the electronic medical record, and the resident's Power of Attorney was not informed of the required follow-up appointments while the resident was in the facility. The facility's administrator expected staff to accurately transcribe and communicate admission orders, but these expectations were not met, leading to the deficiencies noted.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as evidenced by multiple incidents involving staff interactions. One resident, who was cognitively intact and had communication difficulties, reported that a nursing assistant was rough during care, causing shoulder pain, and made dismissive comments about the resident's reaction. Additionally, a certified nurse assistant repeatedly turned off the resident's call light without providing assistance, as the resident was unable to communicate effectively while lying down. Another resident, also cognitively intact, experienced distress due to comments made by agency staff regarding their smoking habits and medical diagnosis of MRSA. The resident reported overhearing staff discussing their reluctance to assist due to the MRSA diagnosis, which led to a refusal to help with necessary transfers. This lack of support and the inappropriate comments made the resident upset and frustrated. A third resident reported that a nursing assistant was very rude during interactions. Interviews with staff and residents confirmed that the nursing assistant had a loud tone and was perceived as rude by multiple residents. The facility's lack of orientation for agency staff and failure to ensure respectful communication contributed to these deficiencies in resident care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bowling Green
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenir At Maple Grove | 10.5 mi | — | 2 | 0 |
| Baptist Homes, Tri-county | 15.4 mi | — | 0 | 0 |
| Silex Community Care | 17 mi | — | 0 | 0 |
| Westview Nursing Home | 20.5 mi | — | 0 | 0 |
| Elsberry Missouri Health Care Center | 24.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.