Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bowling Green Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Unsecured insulin and supplies were left on top of a medication cart outside a resident room, including insulin pens, Lantus insulin, an insulin syringe, lancets, alcohol pads, and a glucometer. The cart was not within sight of a nurse, and RN stated she had gone to the nurse’s station to get papers and should have taken the insulin and supplies with her. The ADON, DON, and Administrator stated medications and related supplies were to be stored or locked when not in use.
A facility failed to complete a Significant Change in Status Assessment (SCSA) MDS for a resident admitted to hospice care, as required by the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The MDS Coordinator was unaware of the requirement, and the DON and Administrator expected compliance with guidelines but did not ensure the specific assessment was completed.
A facility failed to respond to pharmacy recommendations for a resident receiving risperidone, an antipsychotic medication. Despite multiple recommendations to clarify and document the approved diagnosis for the medication, no action was taken. Interviews revealed possible miscommunication or oversight, highlighting a deficiency in addressing medication regimen reviews.
A resident was physically abused by another resident, who was cognitively intact and had no prior behavioral issues. The incident was witnessed by a CNA, but the facility failed to revise the aggressor's care plan post-incident, highlighting a deficiency in implementing their abuse prohibition policy.
A resident with schizoaffective disorder and dementia was involved in an altercation with his roommate, but the facility failed to update his care plan to address the new behavioral issue. Despite the facility's policy requiring care plans to be revised after significant changes, the care plan was not updated, leaving staff without guidance on managing the resident's behavior. Interviews with staff confirmed the oversight, highlighting the need for immediate updates to care plans following such incidents.
Unsecured insulin and supplies left unattended on medication cart
Penalty
Summary
The facility failed to ensure medications, syringes, and lancets were properly secured and supervised on 1 of 4 medication carts. During an observation on 12/17/2025 at 8:02 PM, a surveyor saw a small plastic open-top caddy on top of a medication cart outside room [ROOM NUMBER] on B Hall containing 10 insulin pens, two bottles of Lantus insulin, one insulin syringe, one cup of alcohol pads, one cup of lancets, and one glucometer. The medication cart was not within sight of a nurse, and no residents were observed in the hallway. During interviews, RN 13 stated she normally did not leave insulin and insulin supplies out but had gone to the nurse’s station to get her papers and should have taken the insulin and insulin supplies with her. The ADON stated nurses should not leave medications on the medication cart and that syringes and lancets should be locked in the medication room when not in use. The DON stated insulin and insulin supplies were to be stored when not in use, and the Administrator stated all medications and supplies were expected to be locked in the medication cart or the medication room.
Failure to Complete SCSA MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who was admitted to hospice care. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual requires that an SCSA MDS be completed when a terminally ill resident enrolls in a hospice program. The assessment reference date must be within 14 days from the effective date of the hospice election. In this case, the resident was admitted to hospice care, but the required SCSA MDS was not completed. The deficiency was identified during a review of the resident's medical record, which showed no evidence of a completed SCSA MDS since the resident's admission to hospice care. Interviews with the MDS Coordinator, Director of Nursing (DON), and Administrator revealed a lack of awareness regarding the requirement to complete the SCSA MDS following a resident's placement on hospice. The MDS Coordinator was unaware of the rule, and the DON and Administrator expected assessments to be completed per guidelines but were not aware of the specific requirement in this instance.
Failure to Address Pharmacy Recommendations for Medication Justification
Penalty
Summary
The facility failed to take action after receiving pharmacy recommendations regarding a resident's medication regimen. The resident, who was admitted with a history of Alzheimer's disease and dementia, was receiving antipsychotic medication, specifically risperidone. The pharmacy had recommended on multiple occasions that the facility clarify and document the approved diagnosis to justify the use of risperidone and update the order in the electronic medical record. Despite these recommendations, there was no documented response or action taken by the facility. Interviews with the pharmacist and the resident's primary physician revealed that the recommendations were not addressed, possibly due to miscommunication or oversight. The Director of Nursing expressed an expectation that staff should respond to irregularities identified in the medication regimen review, but this did not occur in this case. The lack of response to the pharmacy's recommendations indicates a deficiency in the facility's process for addressing medication regimen reviews.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On 09/10/2024, a Certified Nursing Assistant (CNA) witnessed Resident 2 (R2) hit Resident 1 (R1) on the cheek. R2 had been admitted to the facility with diagnoses including schizoaffective disorder and dementia, and was considered cognitively intact with no prior behavioral issues noted. R1, who had moderate cognitive impairment, reported bickering with R2 before the incident but stated he was not injured and felt safe in the facility. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the lack of revision to R2's care plan following the altercation. Despite the facility's investigation and interviews with staff and residents, there was no documented evidence of prior issues between R1 and R2. The Director of Nursing and the Administrator confirmed that R2 had no history of behavioral problems and did not recall the incident, indicating a gap in the facility's ability to prevent and address resident-to-resident altercations effectively.
Failure to Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise the Comprehensive Care Plan for a resident following a behavioral change. The resident, who was admitted with diagnoses including schizoaffective disorder and dementia, was involved in an altercation where he hit his roommate. Despite this incident, the care plan, which initially included a behavior management plan, was not updated to reflect the new behavioral issue. The facility's policy requires care plans to be reviewed and updated when there is a significant change in a resident's condition. However, after the altercation, there was no documented evidence that the care plan was revised to include interventions for the resident's change in behavior. Interviews with staff, including the Assistant Director of Nursing and the MDS Coordinator, revealed that the care plan should have been updated immediately by the nurse on the floor or during the clinical meeting by the Interdisciplinary Team. The Director of Nursing and the Administrator both acknowledged that the care plan should have been revised to include a problem of physical aggression with appropriate interventions. The failure to update the care plan could lead to staff not knowing how to properly care for the resident, potentially resulting in further incidents.
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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) |
|---|---|---|---|---|
| Christian Health Center | 1 mi | ★★★★★ | 9 | 0 |
| Signature Healthcare Of Bowling Green | 1.3 mi | ★★★★★ | 2 | 0 |
| Magnolia Village Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Colonial Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Greenwood Rehabilitation And Healthcare Center | 3.6 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 July 2026) and official state health department websites.