Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Manor during CMS and state inspections, most recent first.
The facility failed to ensure required personnel attended quarterly QAA meetings, with no evidence of the Medical Director's attendance at the first quarter meeting and missing documentation for the second and third quarters. This deficiency potentially affected all 93 residents.
The facility failed to provide palatable meals, with residents reporting cold and unappetizing food, particularly French fries. Additionally, the facility did not follow recipes for pureed diets, affecting the nutritive value of meals for residents on such diets. Observations confirmed these deficiencies, and the Dietary Manager acknowledged the issues.
The facility failed to properly puree food for residents requiring dietary modifications. During meal preparation, a staff member initially determined the texture of pureed hamburger to be appropriate, but further inspection revealed small, chewable pieces. A DT confirmed the inconsistency, which did not meet the facility's policy for a smooth, pudding-like texture. This affected four residents receiving pureed food.
The facility failed to ensure proper food labeling, dating, and removal of expired items, and did not maintain adequate hand hygiene practices among kitchen staff. Unlabeled and expired food items were found in the kitchen and activities room refrigerators. A CNA delivered meal trays without performing hand hygiene between rooms, and the Dietary Manager handled food improperly after touching her nose. These actions were confirmed by staff interviews.
A facility failed to ensure accurate assessments for a resident with Alzheimer's and other conditions. The resident's MDS assessment incorrectly indicated a need for a mechanically altered diet and no scheduled pain medication, despite physician orders for a regular diet and Oxycodone with acetaminophen for pain. This was confirmed by an RN during an interview.
The facility failed to implement comprehensive care plans for two residents with nicotine dependence and one resident with edema. Despite being cognitively intact, two residents did not have smoking interventions in their care plans until later revisions, as confirmed by the DON. Another resident with edema and a prescribed lymphedema sleeve lacked appropriate care plan interventions, which was also verified by the DON.
A facility failed to implement bowel interventions for a resident at risk for constipation, as per the facility's bowel protocol. The resident, who was moderately cognitively impaired, did not have a documented bowel movement for eight days. Despite receiving a scheduled laxative, no additional interventions were implemented. Staff confirmed the resident was not included in the bowel protocol list, and no protocol interventions were documented, leading to the deficiency.
Two residents, both cognitively intact and using wheelchairs, were observed smoking on a smoke-free campus. Despite the facility's policy, no smoking assessments were conducted, and smoking materials were not secured by staff. The Administrator was aware of the residents' smoking habits but did not enforce the policy effectively.
A facility failed to conduct pain assessments when administering narcotic pain medication to a resident with multiple diagnoses, including Alzheimer's and lumbosacral disc degeneration. Despite receiving scheduled doses of Oxycodone, no pain assessments were documented in the MAR or TAR. The DON confirmed the lack of assessments, which contradicted the facility's pain management competency guidelines.
QAA Committee Attendance and Documentation Deficiency
Penalty
Summary
The facility failed to ensure the required personnel were in attendance at the quarterly Quality Assessment and Assurance (QAA) meetings, as evidenced by the absence of the Medical Director (MD) at the first quarter meeting and the lack of documentation for the second and third quarter meetings. The review of the QAA meeting sign-in sheets and staff interviews confirmed these deficiencies. Specifically, the first quarter meeting sign-in sheet, dated May 2, 2024, showed no evidence of the MD's attendance. Additionally, there was no documentation available to verify attendance for the second and third quarter meetings held in July and October 2024, respectively. The facility's policy, dated 2018, required the QAA committee to meet at least quarterly with the necessary personnel, but this requirement was not met, potentially affecting all 93 residents in the facility.
Deficiency in Meal Palatability and Pureed Diet Preparation
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the quality of food, specifically noting that vegetables were either under or overcooked, and meals were not warm enough to be enjoyable. Observations confirmed that French fries served during lunch were cold, unappetizing, and lacked flavor. The Dietary Manager verified that the French fries were not cooked appropriately, and the facility's policy emphasized the need for nutritious and palatable meals, which was not adhered to in this instance. Additionally, the facility did not follow recipes for pureed diets, affecting the nutritive value of meals for residents on such diets. During the preparation of pureed meals, an employee added an unspecified amount of hot water to hamburger patties instead of using the recommended condiments or gravy, which was only added later by a Dietetic Technician. This deviation from the recipe compromised the consistency and potentially the nutritional content of the pureed meals, as the facility's policy required meals to meet individual needs and maintain a pudding-like consistency.
Inadequate Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to an appropriate consistency for residents requiring such dietary modifications. During an observation of meal preparation, a staff member added hamburger patties and hot water to a blender and initially determined the texture to be honey thick, which was deemed appropriate. However, upon further inspection, it was found that the hamburger was not fully pureed, containing small, chewable pieces. A Dietetic Technician confirmed that the hamburger was not pureed to a smooth texture as required. The facility's policy and the undated pureed hamburger recipe both indicated that the food should be blended to a smooth, pudding-like consistency, which was not initially achieved. This deficiency affected four residents who were identified as receiving pureed food, out of a facility census of 93.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food labeling, dating, and removal of expired items, as well as adequate hand hygiene practices among kitchen staff. Observations revealed multiple unlabeled and expired food items in the main kitchen's reach-in and walk-in refrigerators, including pitchers of orange liquid, diced peaches, whipped topping, shredded greens, ranch dressing, tuna, and bread with butter packets. Mold was found on hoagie and Italian split-top buns in the dry storage area. Additionally, the refrigerator in the activities room contained undated items such as condiments, coffee creamer, pop, and other food items. Interviews with staff confirmed these findings, and the facility's policy required food to be discarded when expired or within three days of preparation. The facility also failed to ensure proper hand hygiene during meal tray service and food handling. A CNA delivered meal trays to residents without performing hand hygiene between rooms, despite touching multiple surfaces. Similarly, the Dietary Manager donned gloves without washing hands, wiped her nose on her forearm, and then used her gloved hand to retrieve a thermometer from cooked food. These actions were confirmed through staff interviews, and the facility's handwashing policy emphasized the importance of proper handwashing techniques to prevent contamination and infection spread.
Inaccurate Resident Assessment Identified
Penalty
Summary
The facility failed to ensure accurate resident assessments, affecting one of the 19 residents reviewed. Resident #73, who was admitted with diagnoses including late onset Alzheimer's disease, dementia, anxiety, and other conditions, was found to have discrepancies in their Minimum Data Set (MDS) assessment. The MDS assessment dated 01/15/25 incorrectly indicated that the resident required a mechanically altered diet and did not take scheduled pain medication. However, a review of the physician orders revealed that the resident was prescribed Oxycodone with acetaminophen for moderate pain and was on a regular texture and consistency diet. This discrepancy was confirmed during an interview with Registered Nurse #532, who acknowledged the incorrect coding in the MDS assessment.
Failure to Implement Comprehensive Care Plans for Smoking and Edema
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for residents with specific needs related to smoking and edema care. Resident #38, who was cognitively intact and dependent on staff for certain activities, had a diagnosis of nicotine dependence. Despite this, there were no supports or interventions related to smoking in his care plan until it was revised. Observations confirmed that Resident #38 smoked cigarettes, and the Director of Nursing verified the care plan was not updated in a timely manner. Similarly, Resident #88, also cognitively intact and with a diagnosis of nicotine dependence, did not have smoking interventions included in the care plan until a later revision. Observations showed Resident #88 smoking, and the Director of Nursing confirmed the oversight. Additionally, Resident #61, who was cognitively impaired and dependent on staff for dressing, had a medical history of edema and was prescribed a lymphedema sleeve. However, the care plan lacked any interventions related to edema care, which was verified by the Director of Nursing.
Failure to Implement Bowel Protocol for Resident at Risk for Constipation
Penalty
Summary
The facility failed to implement bowel interventions for a resident at risk for constipation, as directed by the facility's bowel protocol. The resident, who was moderately cognitively impaired and required assistance with toileting, did not have a documented bowel movement for eight days. Despite having a physician's order for Docusate Sodium, a laxative, and receiving it as scheduled, no additional interventions were implemented during this period to address the lack of bowel movements. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the resident was not included in the electronic medical record's list for bowel protocol, and no bowel protocol interventions were documented. The facility's bowel protocol required action if a resident had no bowel movement in three days, starting with prune juice and progressing to more invasive measures if necessary. However, these steps were not taken for the resident, leading to the deficiency noted in the report.
Failure to Enforce Smoke-Free Policy and Conduct Smoking Assessments
Penalty
Summary
The facility failed to maintain safe smoking practices for two residents, despite being a smoke-free campus. Resident #38, who is cognitively intact with a BIMS score of 15, was observed smoking on the facility's property. The resident, who is dependent on staff for transfers and uses a manual wheelchair, kept smoking materials in his room and was seen smoking in the facility's parking lot. The Administrator acknowledged awareness of the resident's smoking habits and stated that the resident had been instructed to smoke off the property, but no smoking assessment was conducted to evaluate the resident's ability to smoke safely. Similarly, Resident #88, also cognitively intact with a BIMS score of 15, was observed smoking in the facility's parking lot. This resident, who requires assistance with dressing and transfers, was seen emitting smoke, although no cigarette was visibly lit. The Administrator confirmed that the resident vaped and was aware of the resident's smoking habits. However, like Resident #38, no smoking assessment was completed for Resident #88 due to the facility's non-smoking policy. The facility's Admission Agreement, which prohibits smoking on the campus, was not enforced, and smoking supplies were not secured by staff as required.
Failure to Conduct Pain Assessments with Narcotic Administration
Penalty
Summary
The facility failed to ensure that pain assessments were completed with the administration of narcotic pain medications for a resident. This deficiency was identified during a review of the medical records, staff interviews, and the facility's skills competency for pain management. The resident involved was admitted with multiple diagnoses, including late-onset Alzheimer's disease, dementia, and lumbosacral disc degeneration, among others. Despite having a physician's order for scheduled doses of Oxycodone with acetaminophen for moderate pain, the facility did not document any pain assessments in conjunction with the administration of this medication. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February 2025 showed that the resident received the scheduled doses of Oxycodone as ordered, but there was no evidence of pain assessments being completed. The progress notes from December 2024 to February 2025 only documented three instances of pain assessments, which were not aligned with the administration of the medication. An interview with the Director of Nursing confirmed that pain assessments were not being completed as required, and the facility's Skills Competency Checklist indicated that the resident's response to analgesics should be evaluated.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Wood Haven Health Care Senior Living & Rehab | 2.1 mi | ★★★★★ | 11 | 0 |
| Willows At Bowling Green The | 3.1 mi | ★★★★★ | 1 | 0 |
| Astoria Place Of Waterville | 7.7 mi | ★★★★★ | 31 | 1 |
| Ayden Healthcare Of Waterville | 7.8 mi | ★★★★★ | 34 | 0 |
| St Clare Commons | 8.5 mi | ★★★★★ | 14 | 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.