Bowling Green Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bowling Green Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 29, 2025

  Based on observation, interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide safety during incontinence care for one of 12 residents in the survey sample, Resident #10. The facility staff failed to utilize two staff members to change Resident #10's soiled brief on 5/28/25. Resident #10 fell out of bed and sustained a broken femur. The facility's failure resulted in harm to Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to utilize two staff members to change Resident #10 on 5/28/25. […]

• No harm, potential for more than minimal, patternF684Mar 6, 2025

  Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow physician orders for two of five residents in the survey sample, Residents #1 and #4. The findings include: 1a. For Resident #1 (R1), the facility staff failed to administer antibiotics as ordered. The physician order dated, 10/17/24 at 3:26 p.m. documented, Amoxicillin Oral Tablet (1) 500 MG (milligrams); Give 1 tablet by mouth every morning and at bedtime for dental abscess for 10 days. The MAR (medication administration record) for October 2024, documented the above order. For 10/17/24, the 9:00 p.m. dose documented a 5. A 5 indicates Hold/See Progress notes. […]

• No harm, potential for more than minimal, patternF804Mar 6, 2025

  Based on observation, staff interview and facility document review, it was determined the facility staff failed to serve food at a palatable temperature on one of two units, Unit A. The findings include: The facility staff failed to serve food that was at a palatable temperature on one of two units, Unit A. Observation was made of the kitchen on 3/5/25 at 11:53 a.m. The food temperatures were taken and were as followed: Chicken - 197 degrees Peas - 198 degrees Puree Squash - 177.8 (thrown away) degrees Puree bread - 171 degrees Mashed potatoes - 171 degrees Puree chicken - 140.5 degrees Gravy - 166 degrees Puree peas - 147 degrees Minced moist chicken - 133 - returned to steamed - 12:12 p.m. - 180 degrees. Sweet potato fries at 12:12 p.m. […]

• No harm, potential for more than minimal, patternF812Mar 6, 2025

  Based on observation, staff interview and facility document review, it was determined the facility staff failed to store and serve food in a sanitary manner in one of one kitchen and on one of two units. The findings include: Observation was made of the kitchen on 3/5/25 at 11:39 a.m. The freezer was observed with an open bag of frozen rolls, that was not labeled or dated. A box of southern style biscuit dough was open and the bag inside was open to air. No label or date noted on the box. An interview was conducted with OSM (other staff member) #1, the cook, who stated she doesn't remember labeling and dating a box in the freezer. On 3/5/25 at 12:07 a.m. OSM #2, a dietary aide, was preparing for the tray line to start. She had on her gloves and was resting her chin on her gloved hands. […]

• No harm, potential for more than minimal, patternF812Mar 28, 2024

  Based on observation, staff interview, and facility document review, the facility staff failed to store food in a sanitary manner in one of one kitchen. The findings include: 1. The facility staff failed to store a scoop used for dry pureed bread mix in a sanitary manner. On 3/26/24 at 11:30 a.m., 3/26/24 at 4:30 p.m., and 3/27/24 at 10:20 a.m., a scoop was observed sitting inside of a container of dry pureed bread mix. The handle of the scoop was touching the inside of the container. On 3/27/24 at 1:11 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary manager). OSM #5 stated sometimes the cook uses the scoop inside the dry pureed bread mix throughout the day and at the end of the day, he washes the scoop and hangs it up. […]