Bowling Green Manor

In the surveyor’s words

From the most serious findings on record at Bowling Green Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF868Feb 18, 2025

  Based of review of the Quality Assessment and Assurance (QAA) committee meeting sign in sheets, staff interview and review of facility policy, the facility failed to ensure the required personnel were in attendance at the quarterly QAA meetings and further failed to maintain documentation of personnel in attendance at all QAA meetings This had the potential to affect all residents. The facility census was 93. Findings include: Review of the first quarter QAA meeting sign in sheet, dated 05/02/24, revealed no evidence the Medical Director (MD) was in attendance at the meeting. Further review of documentation for the second quarter QAA meeting, held in July 2024, and the third quarter QAA meeting, held in October 2024, revealed no evidence of who was in attendance at the meetings. […]

• No harm, potential for more than minimal, patternF804Feb 18, 2025

  Based on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure resident meals were palatable. This affected all residents, except 31(#6, #8, #10, #18, #22, #24, #25, #26, #35, #39, #40, #44, #49, #52, #58, #61, #65, #67, #71, #75, #77, #84, #90, #92, #95, #148, #152, #245, #246, #247, #248) residents the facility identified as not being served French fries. Additionally, the facility failed to ensure recipes for pureed diets were followed to maintain nutritive value. This affected four (#8, #39, #61 and #90) of four residents identified by the facility as receiving pureed meals. The facility census was 93. Findings include: 1. Interview on 02/10/25 at 8:15 P.M. […]

• No harm, potential for more than minimal, patternF805Feb 18, 2025

  Based on observation, staff interview, review of the pureed food recipe and review of facility policy, the facility failed to ensure pureed foods were prepared to an appropriate consistency. This affected four (#8, #39, #61, and #90) of four residents identified by the facility as receiving pureed food. The facility census was 93. Findings include: Observation on 02/12/25 at 10:20 A.M. of pureed meal preparation revealed [NAME] #439 added hamburger patties and hot water to the puree blender. At 10:24 A.M., [NAME] #439 stopped the blender, took off the lid, and used her gloved fingers to test the texture of the pureed meat. […]

• No harm, potential for more than minimal, patternF812Feb 18, 2025

  Based on observation, staff interview and review of facility policy, the facility failed to ensure food was properly labeled and dated and further failed to remove items from stock when expired. Additionally, the facility failed to ensure kitchen staff performed adequate hand hygiene. This had the potential to affect all residents, except one (#248) resident identified by the facility as receiving no nutrition from the kitchen. Lastly, the facility failed to ensure meals were distributed in a manner that protected against contamination. This affected three (#32, #57, and #69) of 17 residents who received meal trays on the B Hall. The facility census was 93. Findings include: 1. Observations on [DATE] between 6:25 P.M. and 7:24 P.M. […]

• No harm, potential for more than minimal, isolatedF641Feb 18, 2025

  Based on medical record review and staff interview, the facility failed to ensure resident assessments were completed accurately. This affected one (#73) of 19 residents reviewed for assessments. The facility census was 93. Findings include: Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnoses included late onset Alzheimer's disease, dementia, anxiety, lumbosacral disc degeneration, abnormalities of gait and mobility, oropharyngeal dysphagia, hypertension, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/15/25, revealed Resident #73 required a mechanically altered diet and did not take scheduled pain medication. […]