Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Bowerston Hills Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident requiring enhanced barrier precautions did not receive proper infection control during a dressing change, as a nurse practitioner failed to perform hand hygiene or change gloves between wound sites, contrary to facility policy. Additionally, the facility did not follow its water management plan for Legionella prevention, as water temperatures were checked at faucets instead of water heaters and did not meet required levels.
A resident with significant mobility needs and a preference to be assisted out of bed on weekends was not transferred as requested, with no documentation of refusal or clinical justification. Staff interviews indicated inconsistent adherence to the resident's preferences, resulting in a failure to support resident self-determination.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall with injury and a change in elopement risk status, but the care plan was not updated to reflect these changes. The interdisciplinary team did not meet to review or revise the care plan, and required interventions and documentation were not completed according to facility policy.
A resident with severe cognitive impairment and multiple comorbidities was treated with antibiotics for a suspected UTI without timely review of urine or blood culture results. Despite negative culture findings, antibiotics were continued due to delayed communication and lack of documentation, reflecting a breakdown in antibiotic stewardship practices by nursing and medical staff.
A resident with cognitive impairment and multiple chronic conditions did not receive an influenza vaccination despite signed consent from their representative. The vaccine was not administered due to unavailability, and there was no documentation of notification to the representative or the DON, nor was the missed vaccination recorded in the medical record as required by facility policy.
Infection Control and Water Management Deficiencies Identified
Penalty
Summary
During a dressing change for a resident with multiple complex medical conditions, including acute respiratory failure, muscular dystrophy, and dependence on a ventilator, infection control measures were not properly implemented. The resident was under enhanced barrier precautions due to wounds, a tracheostomy, and a gastrostomy tube. Observation revealed that the nurse practitioner and an LPN wore gowns and gloves, but the nurse practitioner failed to perform hand hygiene or change gloves between handling two separate wound sites. The same gloves were used throughout the procedure, including while cleansing wounds, applying dressings, and repositioning the resident. The nurse practitioner confirmed during an interview that hand hygiene and glove changes should have occurred but were not performed. Facility policy required hand hygiene and glove changes between wound care steps, which was not followed in this instance. Additionally, the facility failed to adhere to its written water management plan for Legionella prevention. The plan required weekly water temperature checks at each water heater to ensure temperatures were maintained at 140 degrees Fahrenheit. However, review of logs showed that temperatures were recorded from faucets, not directly from the water heaters, and the recorded temperatures ranged from 100 to 119 degrees Fahrenheit over several months. The maintenance director confirmed that the procedure did not follow the facility's established water management plan.
Failure to Support Resident Choice for Weekend Transfers
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination by not assisting a resident out of bed on weekends according to her preference. The resident, who had diagnoses including major depressive disorder, insomnia, weakness, constipation, and cerebral palsy, required extensive two-person assistance and a Hoyer lift for transfers. Documentation showed that on multiple weekends, the resident was not transferred out of bed, and there was no record of refusal or clinical reason for remaining in bed on those days. The care plan included interventions to encourage activity and participation in daily living, but these were not consistently implemented. Interviews with the resident and staff revealed that the resident wanted to get out of bed on weekends but was not assisted by staff, who cited reasons such as loose stools, diarrhea, or the resident's occasional refusal. However, there was no documentation to support that the resident refused or that clinical conditions prevented transfers on the specific dates in question. Staffing patterns on weekends were also noted, but the lack of documentation and failure to follow the resident's expressed preferences led to the deficiency.
Failure to Revise Care Plan After Fall and Change in Elopement Risk
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following a fall and a change in elopement risk status. The resident, who had multiple diagnoses including parkinsonism, dementia with behavioral disturbances, and a history of traumatic brain injury, was assessed as having severely impaired cognition and had experienced a fall with injury. Despite documentation in the medical record indicating the resident was no longer at risk for elopement and had sustained a significant fall resulting in head and elbow injuries, the care plan was not updated to reflect these changes. The care plan continued to list the resident as at risk for wandering and elopement, and no new interventions were added after the fall, even though the resident was moved closer to the nurses' station for observation. Review of facility documentation and interviews revealed that the interdisciplinary team did not meet to review or revise the fall risk care plan after the incident, and the MDS Coordinator had not updated the care plan due to not being aware of the latest assessments. The facility's own policies required that care plans be updated immediately after a fall investigation and that new interventions be communicated to staff, but these steps were not followed. Additionally, the fall investigation documentation lacked post-fall follow-up information and did not include newly added interventions.
Failure to Implement Antibiotic Stewardship for UTI Management
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program regarding the use of antibiotics for a resident with multiple complex medical conditions, including dementia, diabetes, and schizoaffective disorder. The resident was admitted with symptoms suggestive of a urinary tract infection (UTI) and was subsequently sent to the emergency department for evaluation due to low blood pressure, lethargy, and blood-tinged urine. Following hospital admission and discharge, the resident was prescribed cefdinir for a UTI, and later, an order for Keflex was received but subsequently canceled in favor of continuing cefdinir. Despite these interventions, there was no evidence in the medical record of timely receipt or review of urine or blood culture results from the hospitalizations, nor documentation of urinalysis or culture and sensitivity reports for the relevant periods. Attempts to obtain culture results were delayed, with only one documented fax request several days after the initial hospitalization. When the results were finally received, both urine cultures from separate hospitalizations showed no bacterial growth. Staff interviews revealed uncertainty about the receipt of culture results and a lack of timely communication with the physician regarding the negative findings, resulting in the continued administration of antibiotics without supporting evidence of infection. This sequence of events demonstrates a failure to monitor and evaluate antibiotic use in accordance with stewardship principles.
Failure to Administer Influenza Vaccine per Consent and Policy
Penalty
Summary
A resident with multiple diagnoses, including dementia, hypertension, obesity, type 2 diabetes, schizoaffective disorder, auditory hallucinations, hypothyroidism, depression, and chronic obstructive pulmonary disease, was admitted to the facility. The resident's appointed representative signed a consent form authorizing administration of the influenza vaccine. Despite this consent, review of the resident's medical records, including the medication and treatment administration records for March and April, showed no documentation that the influenza vaccine was administered. Further investigation revealed that the facility had run out of influenza vaccine and did not notify the Director of Nursing or the resident's representative about the unavailability or the missed vaccination. The facility's policy requires that residents admitted during flu season be offered the vaccine within five working days of admission, and that administration or refusal be documented. In this case, there was no documentation of vaccine administration, nor was there evidence that the representative was informed of the missed vaccination.
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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 Bowerston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyslope Nursing Home | 1.4 mi | — | 1 | 0 |
| Claymont Health And Rehabilitation | 9.1 mi | — | 2 | 0 |
| Schoenbrunn Healthcare | 10.5 mi | — | 6 | 0 |
| Carroll Healthcare Center Inc | 11.2 mi | — | 2 | 0 |
| Park Village Hc Np Llc | 13 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.