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 Bowling Green Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident who was completely dependent on staff for bed mobility and required a two-person assist was provided incontinence care by only one CNA. During the care, the resident fell from bed and sustained a fractured femur. Staff interviews confirmed knowledge of the two-person assist requirement, and documentation supported the resident's need for this level of assistance.
A resident who was completely dependent for bed mobility and required a two-person assist for incontinence care experienced a fall when only one CNA provided care, contrary to the care plan. The CNA pulled the draw sheet, causing the resident to fall from bed and sustain knee pain. Staff interviews confirmed awareness of the two-person assist requirement, but it was not followed due to staffing availability at the time.
Staff failed to accurately monitor and document a resident's breakfast intake, recording that the resident consumed most of the meal when, in fact, only beverages were consumed. The CNA did not verify the amount eaten or consult the resident, despite care plan requirements and facility policy for meal intake documentation.
Facility staff administered hydralazine to a resident for hypertension on multiple occasions despite physician orders to hold the medication if the systolic blood pressure was below 140. The MAR and staff interviews confirmed that the medication was given outside of the prescribed parameters, contrary to facility policy requiring adherence to prescriber orders.
Staff did not follow enhanced barrier precautions during high-contact care for a resident with a chronic wound, as required by facility policy. During ADL care, including incontinence care, dressing, and linen changes, staff wore gloves but failed to wear gowns, despite posted signage and available supplies indicating the need for both gown and gloves.
Staff failed to administer antibiotics and other medications according to physician orders for two residents, including missing doses, delaying antibiotic therapy, and not holding medication when blood pressure parameters were exceeded. Additionally, staff did not notify the nephrologist as ordered when a resident's blood pressure readings were above set limits, and there was no documentation of required notifications in the clinical record.
Staff did not serve food at a palatable temperature on one unit, as observed by surveyors and confirmed by a cook. Food items experienced significant temperature drops between kitchen preparation and resident service, resulting in meals that were cold and not appetizing. The issue was noted during a meal service where food was served on styrofoam trays and residents requiring feeding assistance experienced further delays.
Staff failed to maintain sanitary food storage and serving practices, including unlabeled and improperly stored frozen foods in the kitchen, improper glove use by dietary staff, and a CNA consuming a personal drink in a resident area during mealtime. These actions did not comply with facility policies on food safety and hygiene.
A resident with multiple cardiac risk factors had a care plan requiring daily BP monitoring and physician notification for elevated readings. Despite several instances of high BP and administration of PRN hydralazine, there was no documentation that the nephrologist or physician was notified as required by orders and the care plan.
Staff did not update the care plan for a resident with severe cognitive impairment to include the use of a wander guard, despite a physician order and the resident's elopement risk. The omission was confirmed by an RN, and facility policy requires such updates to care plans.
Failure to Provide Required Two-Person Assist During Incontinence Care Resulting in Resident Fall and Injury
Penalty
Summary
Facility staff failed to provide adequate supervision and safety during incontinence care for a resident who was completely dependent on staff for bed mobility and required a two-person assist, as documented in her care plan and Kardex. On the morning of the incident, only one CNA was present to provide incontinence care, despite the resident's need for two staff members for safe bed mobility. During the care, the CNA pulled the draw sheet while the resident attempted to hold onto the grab bar, resulting in the resident losing her grip and falling out of bed onto her knees. The resident, who was cognitively intact but at risk for falls due to muscle weakness and recent hospitalization, reported significant pain following the fall. Initial assessment noted knee pain without visible injury, but subsequent evaluation and imaging revealed a fracture of the distal femur. Staff interviews confirmed awareness of the two-person assist requirement, and the CNA involved acknowledged that the absence of a second staff member contributed to the fall. The facility's fall prevention policy did not address the specific circumstances of this incident.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
Facility staff failed to implement the care plan for one resident who was assessed as cognitively intact but completely dependent on staff for bed mobility following a recent hospitalization. The resident's care plan and Kardex both specified a two-person assist for bed mobility and incontinence care, with the use of a draw sheet or lift sheet for turning and repositioning. On the morning in question, only one CNA provided incontinence care, contrary to the care plan requirements. During this care, the CNA pulled the draw sheet, causing the resident to fall from the bed onto her knees, resulting in significant knee pain. The resident confirmed that sometimes two CNAs are present for care, but at other times only one is available. Staff interviews revealed that the CNA was aware of the two-person assist requirement but proceeded alone because other staff were occupied. The LPN confirmed that staff are informed of care requirements via the Kardex and that the charge nurse is responsible for ensuring care plans are followed. Facility documentation and policy review further supported that individualized care plans are to be developed and implemented to meet each resident's needs. The failure to follow the care plan directly led to the resident's fall and subsequent pain.
Failure to Accurately Monitor and Document Meal Intake
Penalty
Summary
Facility staff failed to provide nutritional care and services consistent with a resident's comprehensive care plan by not accurately monitoring and documenting a resident's breakfast meal intake. The resident, who was cognitively intact and had a history of sepsis, COPD, GERD, bipolar disorder, and significant weight gain, was care planned for meal intake monitoring and documentation at each meal. On the specified date, the resident consumed only coffee and juice at breakfast and did not eat any of the provided food items. The CNA responsible for monitoring and documenting meal intake removed the tray without checking the amount of food consumed and subsequently recorded that the resident had eaten 51% to 75% of the meal. Interviews revealed discrepancies between the CNA's documentation and the resident's account, as the resident stated he did not eat breakfast and that his wife did not consume any food from his tray. The CNA admitted to documenting intake based on observation of the plate rather than confirming with the resident, despite knowing that the resident's wife sometimes ate from the tray. The facility's policy required meal intake to be documented after each meal, but this was not followed in this instance, resulting in inaccurate documentation of the resident's nutritional intake.
Failure to Adhere to Physician-Ordered Parameters for Antihypertensive Medication
Penalty
Summary
Facility staff failed to ensure that a resident’s drug regimen was free from unnecessary medications by not adhering to physician-ordered parameters for administering hydralazine, an antihypertensive medication. The physician’s order specified that hydralazine should be held if the resident’s systolic blood pressure (SBP) was less than 140. Despite this, the medication administration record (MAR) showed that the resident received hydralazine on three occasions when their SBP was below the prescribed threshold (134, 137, and 138). These administrations were documented with check marks on the MAR, indicating the medication was given outside of the ordered parameters. A nurse’s note confirmed that the medication was administered outside of the prescribed parameters and that the nurse practitioner and responsible party were made aware. During an interview, an LPN acknowledged that the medication should not have been given on those dates, as the nurses did not pay attention to the physician’s hold parameter. The facility’s policy requires medications to be administered in accordance with prescriber orders, but this was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to follow infection control practices during activities of daily living (ADL) care for one resident who was on enhanced barrier precautions (EBP) due to a venous/stasis ulcer related to peripheral vascular disease. The resident was assessed as dependent for toileting, dressing, and transfers, and had a chronic wound requiring dressing applications. Facility policy and posted signage required staff to wear both gown and gloves when providing high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, and incontinence care for residents on EBP. On the observed date, a certified nursing assistant provided incontinence care, changed a soiled brief, dressed the resident, and changed soiled bed linens while only wearing gloves and not a gown, as required. Subsequently, a licensed practical nurse assisted with transferring the resident from bed to wheelchair, also without wearing a gown. Interviews with staff confirmed their awareness of the EBP requirements and the facility's policy, but the required use of gowns during high-contact care was not followed during the observed care activities.
Failure to Follow Physician Orders for Medication Administration and Physician Notification
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to medication administration and physician notification. For one resident, staff did not administer antibiotics as ordered for a dental abscess. The medication administration record (MAR) showed a missed dose of Amoxicillin without documentation of the reason, and there was a 36-hour gap between the end of one antibiotic course and the start of another, despite backup medication being available in the Omnicell system. Interviews with nursing staff and the director of nursing confirmed that antibiotics should be started promptly and any delays or actions taken should be documented, which was not done in this case. Additionally, staff failed to follow orders for the administration of Midodrine, a medication for hypotension. The physician order specified that the medication should be held if the systolic blood pressure (SBP) was greater than 115. However, the MAR documented that the medication was administered even when the SBP exceeded this threshold. Nursing staff acknowledged that the medication should have been held under these circumstances, as per the order. For another resident, staff did not notify the nephrologist as required when blood pressure readings exceeded the set parameters. The physician order required daily blood pressure monitoring and notification to nephrology for SBP over 140 or diastolic blood pressure (DBP) over 90. Multiple instances were found where blood pressure readings were above these limits, but there was no evidence in the progress notes that the nephrologist was notified. Additionally, when hydralazine was administered for elevated SBP, there was no documentation of physician notification as required by the order.
Failure to Serve Food at Palatable Temperatures on Unit A
Penalty
Summary
Facility staff failed to serve food at a palatable temperature on Unit A, as evidenced by direct observation, staff interviews, and review of facility documents. On the day of the survey, food temperatures were measured in the kitchen prior to service and found to be within appropriate hot-holding ranges. However, by the time the last cart was delivered to Unit A and the last resident began eating, significant drops in food temperature were recorded. The test tray, prepared to represent the meal served, showed that items such as pureed bread, mashed potatoes, pureed peas, pureed chicken, minced moist chicken, chicken steak sandwich, and sweet potato fries had all dropped to temperatures between 93 and 116 degrees Fahrenheit, which were described as cold, not warm to eat, and not palatable by both the cook and the surveyor. The food was served on white styrofoam trays due to anticipated kitchen construction, which may have contributed to the temperature loss. Staff interviews indicated that the last cart served was for residents requiring feeding assistance, with 8-10 residents needing such help. On the day in question, feeding was conducted one-to-one, which may have further delayed meal service. The facility's policy requires food to be served at a safe and appetizing temperature, but this standard was not met for the residents on Unit A during the observed meal service.
Deficient Food Storage and Sanitary Practices Observed
Penalty
Summary
Facility staff failed to store and serve food in a sanitary manner, as observed in both the kitchen and a resident unit. In the kitchen, an open bag of frozen rolls and a box of southern style biscuit dough were found without labels or dates, and the biscuit dough was left open to air. The cook was unable to recall labeling or dating the items. Additionally, a dietary aide was seen resting her chin on gloved hands and later standing with gloved hands folded across her chest, indicating improper glove use during food preparation. During mealtime in the day room, a certified nursing assistant was observed drinking from a personal bottle of soda and returning it to a shelf next to a fast-food drink cup, while another CNA was feeding a resident nearby. The director of nursing confirmed that personal drinks should be kept in the unit manager's office and not in resident areas or consumed during care. Facility policies require proper hand washing, glove use, and correct food storage practices, including labeling and dating food items and preventing cross-contamination, which were not followed in these instances.
Failure to Implement Cardiac Care Plan and Notify Physician of Elevated Blood Pressure
Penalty
Summary
Facility staff failed to implement the comprehensive care plan for one resident with significant cardiac risk factors, including chronic kidney disease, hyperlipidemia, hypertension, coronary artery disease, and peripheral vascular disease. The care plan required daily blood pressure monitoring and notification to nephrology if systolic blood pressure (SBP) exceeded 140 or diastolic blood pressure (DBP) exceeded 90. Despite multiple documented instances where the resident's SBP was above 140, there was no evidence in the progress notes that the nephrologist was notified as required by the physician's order and the care plan. Additionally, the resident had a physician order for hydralazine to be administered as needed for SBP greater than 160. On several occasions, the medication was administered for elevated SBP, but again, there was no documentation that the physician was notified of blood pressure readings above 140, as required. Staff interviews confirmed that the care plan is intended to guide resident care and should be followed. Facility policy also mandates the development and implementation of individualized care plans to provide effective, person-centered care, but this was not adhered to in this case.
Failure to Update Care Plan for Wander Guard Use
Penalty
Summary
Facility staff failed to review and revise the care plan for one resident to include the use of a wander guard device. The resident in question was identified as being at risk for elopement due to severe cognitive impairment, as evidenced by a recent Minimum Data Set (MDS) assessment indicating significant difficulty in making daily decisions. A physician order was in place requiring daily checks of the wander guard's function and placement, as well as skin assessments for breakdown at the site of device placement. However, the comprehensive care plan, while noting the resident's elopement risk and need for risk assessments, did not document the use of the wander guard as an intervention. During staff interviews, a registered nurse confirmed that the use of a wander guard should have been included in the care plan and acknowledged that this intervention had been accidentally omitted. Facility policy requires that care plans be updated as changes occur and reviewed quarterly, but documentation failed to show that the care plan was revised to reflect the physician's order for the wander guard. Administrative staff, including the administrator, DON, and regional director of operations, were made aware of the deficiency.
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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) |
|---|---|---|---|---|
| Heritage Hall King George | 18 mi | — | 0 | 0 |
| Woodmont Center | 18.4 mi | — | 5 | 0 |
| Fredericksburg Health And Rehab | 19.3 mi | — | 2 | 0 |
| Carriage Hill Health & Rehab Center | 19.7 mi | — | 2 | 0 |
| Ashland Nursing And Rehabilitation | 20.8 mi | — | 12 | 2 |
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