Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Greenwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors observed significant water damage and mold-like substances in a hallway and a shared resident room, including wet ceilings, ceiling holes, and debris. An LPN and the Maintenance Director confirmed ongoing condensation and drainage issues, with persistent water stains and possible mold above residents' beds. The Maintenance Director was unaware of the resident room issues until notified by surveyors, and no work order had been initiated.
A resident with severe cognitive impairment and multiple medical conditions experienced several falls that were not accurately documented in the MDS assessments. Despite incident reports and EMR entries confirming the falls, the MDS indicated no falls had occurred, resulting in incomplete assessment of injury extent. The errors were only identified after surveyor review, and the facility lacked a specific MDS policy, relying on general state and federal guidelines.
A resident with severe cognitive impairment and a history of multiple falls did not receive all care plan interventions, including the use of non-skid strips at the bedside and consistent supervision in high-visibility areas. Staff were unaware or did not implement these interventions, and the resident was repeatedly observed without required safety measures in place.
Two residents were not given the opportunity to participate in the development of their care plans, as required by facility policy. Documentation was lacking regarding invitations, attendance, and follow-up for care plan meetings. Both residents reported not being invited to participate, and staff could not provide evidence of proper notification or attendance records.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in an unsafe environment for residents.
Surveyors found expired intravenous antibiotics in the medication refrigerator labeled for two residents with complex medical conditions. Staff interviews revealed inconsistent practices and unclear responsibilities for removing expired medications, and the facility's policy did not address expiration dates or discarding procedures.
Multiple residents did not receive meals that matched their documented preferences or dietary restrictions, including missing preferred beverages, incorrect food textures, and provision of foods contraindicated for medical conditions. Staff were unable to explain discrepancies, and meal cards were not consistently followed.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents requiring infection control measures: one with a feeding tube and another with a sacral wound. In both cases, staff did not wear gowns during high-contact care activities, despite care plans and facility policy requiring EBP. Signage and PPE availability were inconsistent, and staff misunderstood or disregarded EBP requirements, resulting in noncompliance with infection prevention protocols.
A working call system was not available in each resident's bathroom and bathing area, as required. This deficiency was observed during the survey and indicates that residents did not have access to a functional means of requesting assistance in these areas.
Failure to Maintain Sanitary and Functional Environment Due to Water Damage and Mold
Penalty
Summary
The facility failed to maintain a functional and sanitary environment, as evidenced by multiple observations of water damage and mold-like substances in the 300 Hall and in a shared resident room. On several occasions, surveyors observed a large wet spot on the carpet, a bucket filled with water and a soiled glove under a hole in the hallway ceiling, and ceiling debris on the floor. There was also a significant water stain extending to an overhead light fixture, which was subsequently removed due to water accumulation. The Maintenance Director confirmed that the water issues were due to condensation problems in the attic and a clogged condensation drain, but the ceiling and light fixture remained unrepaired for several days. In a shared resident room, both residents' ceiling areas showed water damage, with one area above a resident's bed displaying large water stains and a dark grey/green mold-like substance. Another area had a sizable water stain and a hole with visible fuzzy, dark grey/green material. These conditions persisted over multiple days, with the Maintenance Director confirming the presence of wetness and possible mold. The Maintenance Director also stated he was unaware of the issues in the resident room prior to notification by the surveyor, and no work order had been initiated to address the problem. The Administrator attributed the water damage to condensation issues.
Inaccurate MDS Fall Documentation for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the fall history of a resident with severe cognitive impairment and multiple medical diagnoses, including a left femur fracture, adult failure to thrive, and chronic atrial fibrillation. Despite documented falls occurring on several dates, the MDS assessments for this resident repeatedly indicated that no falls had occurred since admission or the prior assessment. Specifically, the MDS assessments with Assessment Reference Dates (ARDs) of 04/11/2025, 05/05/2025, and 07/08/2025 all recorded 'No' for the question regarding falls, even though incident reports and the electronic medical record documented falls on 03/13/2025, 04/17/2025, 06/13/2025, and 06/17/2025. As a result, follow-up questions regarding the extent of injury from falls were not activated in the MDS, leading to incomplete documentation of the resident's fall history. Interviews with the MDS nurse revealed that the inaccuracies were only discovered after state surveyors requested copies of the MDS assessments. The nurse acknowledged that the errors occurred and attributed them to the information 'falling through the cracks.' The facility did not have a specific policy on MDS completion, instead stating that they follow state and federal guidelines and the Resident Assessment Instrument (RAI) manual. The administrator indicated that staff communication and adherence to facility policies were intended to keep residents safe, but the documentation did not reflect the actual events that occurred.
Failure to Implement Comprehensive Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a history of multiple falls and severe cognitive impairment. The resident, admitted with chronic atrial fibrillation, multiple fractures, osteoporosis, dementia, and adult failure to thrive, experienced several falls over a period of months. The care plan included interventions such as keeping the resident in high-visibility areas when in a wheelchair, ensuring the resident was up in a wheelchair during daytime hours, and placing non-skid strips at the bedside. However, repeated observations revealed that non-skid strips were not present at the resident's bedside on multiple occasions, despite this being a documented intervention. Additionally, the resident was observed left unsupervised in both his room and in the hallway, contrary to the care plan's directive for high-visibility supervision. Interviews with staff indicated a lack of awareness and implementation of the care plan interventions. A CNA was unaware that non-skid strips were required, and the RN confirmed that this intervention was not included in the care guide used by staff. The DON acknowledged that non-skid strips were not in place until prompted by surveyor questions. The resident's family member expressed concern about the frequency of falls, and staff interviews confirmed that the care plan was not consistently followed, particularly regarding supervision and environmental safety measures.
Failure to Ensure Resident Participation in Care Plan Development
Penalty
Summary
The facility failed to ensure that two residents were given the opportunity to participate in the development of their care plans, as required by both facility policy and regulatory standards. Review of the facility's policy indicated that residents and their representatives should be invited to care plan meetings, with documentation of invitations, attendance, and any follow-up efforts. However, for both residents reviewed, there was no documented evidence that they were informed of the specific date, time, or location of their care plan meetings, nor was there evidence of their attendance or participation in the care planning process. Progress notes contained vague references to contact with residents or their representatives, but lacked specific details and did not confirm who was contacted or how the information was provided. For one resident, who was cognitively intact and had been in the facility since 2016, there was no documentation of attendance at care plan meetings for two separate care plan reviews in 2025. The resident reported not being regularly invited to care plan meetings and expressed a desire to participate. The Social Services Director (SSD) was unable to find evidence of invitations or attendance records for this resident and could not explain the lack of documentation. Similarly, for the second resident, there was no evidence of participation in care plan meetings, and the resident stated he had not been invited or informed about them. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for scheduling and documenting care plan meetings. The SSD and other staff members acknowledged that invitations were supposed to be issued and attendance documented, but could not provide evidence that this had occurred. The letter used to notify residents did not include specific meeting details and implied the care plan had already been developed, rather than inviting participation in its creation. There were no sign-in sheets or other documentation to confirm resident or representative attendance, and discarded scheduling records further contributed to the lack of evidence.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Expired Medications Not Removed from Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards, specifically regarding the removal and discarding of expired medications. During an observation of the medication refrigerator on the 300 hall, surveyors found four elastomeric ball pumps containing piperacillin/tazobactam labeled for one resident and six elastomeric ball pumps containing gentamicin labeled for another resident, all of which were expired. The facility's medication storage policy did not address expiration dates or the process for discarding expired medications. Interviews with staff, including a Certified Medication Technician, the Assistant Director of Nursing, the Director of Nursing, and the Administrator, revealed inconsistent practices and unclear responsibilities regarding the removal of expired medications, with some staff indicating that nurses, pharmacy technicians, or pharmacy staff were responsible for this task. The residents involved had significant medical histories, including second degree burns, chronic pain, autistic disorder, type 2 diabetes mellitus, allergies to antibiotics, muscle weakness, and chronic kidney disease. The expired medications found were intravenous antibiotics, which had not been removed from the medication refrigerator after their expiration dates. Staff interviews confirmed that expired medications remained in the medication room refrigerator, and there was a lack of clear, consistent oversight to ensure timely removal and disposal of these medications.
Failure to Accommodate Resident Food Preferences and Dietary Orders
Penalty
Summary
The facility failed to ensure that residents received food that accommodated their allergies, intolerances, and preferences, as required by policy. For one resident, the care plan indicated that food preferences should be assessed and updated, but the nutritional assessment lacked specific preferences. During a lunch observation, the resident received only one serving of vegetables despite a meal card indicating two choices, and the resident reported receiving foods contraindicated for her dialysis, such as potatoes and bananas. The CNA delivering the tray was unable to identify or explain the absence of the second vegetable. Additional observations revealed that another resident did not receive their preferred almond milk, while a third resident was missing both a can of lemon lime soda and chocolate milk. Furthermore, a resident who was not supposed to have straws was observed with a straw in their drink, and another resident on a ground diet received a dessert that was not ground. The administrator confirmed that physician diet orders were to be followed and that resident preferences should be accommodated within those orders.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) as required for two residents. One resident, admitted with a gastrostomy tube and dementia, had physician orders and a care plan indicating the need for EBP due to the presence of an indwelling medical device. During personal care, a CNA provided hygiene without wearing a gown, despite signage and care guides indicating EBP was required. The CNA initially believed the other resident in the room was on EBP, but upon review of the care guide and door signage, it was confirmed that the resident receiving care was the one requiring EBP. The CNA acknowledged the failure to don a gown during high-contact care activities. Another resident with a sacral pressure wound had orders and a care plan for EBP. During a wound dressing change, there was no signage indicating EBP, and no PPE was available at the room entrance. The treatment nurse did not wear a gown while performing the dressing change, even though fecal material was present near the wound site. The nurse stated EBP was not needed because the wound was not colonized with infectious organisms, contrary to facility policy and physician orders that required EBP for wounds regardless of colonization status. Interviews with facility leadership, including the Infection Preventionist, Medical Director, DON, and Administrator, confirmed that EBP should have been implemented for both residents as per policy and orders. The failure to use gowns during high-contact care activities for residents with indwelling devices and wounds constituted a breach of the facility's infection prevention and control program.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The report does not provide additional details about specific residents affected, their medical history, or their condition at the time the deficiency was observed.
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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) |
|---|---|---|---|---|
| Magnolia Village Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Christian Health Center | 3.2 mi | ★★★★★ | 9 | 0 |
| Bowling Green Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 4 | 0 |
| Colonial Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 2 | 0 |
| Signature Healthcare Of Bowling Green | 4.7 mi | ★★★★★ | 2 | 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.