Bowling Green Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Feb 9, 2021

  Based on interview, closed record review, hospital record review, review of Resident Assessment Instrument (RAI) Manual, and facility policy review, it was determined the facility failed to have an effective system in place to ensure care plans were developed and implemented to prevent skin breakdown for one (1) of five (5) sampled residents (Resident #1). The facility readmitted Resident #1 on [DATE] and care planned the resident for Skin Breakdown. An intervention was initiated that directed staff to assess the resident's skin and report redness, rashes, bruises, abrasions, and skin breakdown. State Registered Nurse Aide (SRNA) #1 reported she identified an area that looked like a bruise above the resident's buttock crack on [DATE] and reported the area to the nurse. […]

• Immediate jeopardy, isolatedF686Feb 9, 2021

  Based on interview, closed record review, hospital record review, and facility policy review, it was determined the facility failed to ensure skin and wound assessments were completed, and pressure ulcers treated according to standards of practice to prevent pressure ulcer development or further decline for one (1) of five (5) sampled residents, Resident #1. State Registered Nurse Aide (SRNA) #2 stated when providing incontinent care on [DATE], she noted a discolored area above resident's buttock crack that resembled a bruise. SRNA stated she reported the area to the nurse but could not recall which nurse. However, there was no documented evidence the facility assessed the discolored area on buttocks. […]

• No harm, potential for more than minimal, isolatedF689Dec 20, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure medications, syringes, and lancets were properly secured and supervised on 1 of 4 medication carts.The findings include: A facility policy titled, Safety and Supervision Standard of Practice, revised 02/2021, revealed, Purpose: The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision are facility-wide priorities. During an observation on 12/17/2025 at 8:02 PM, the surveyor noted a small, plastic, opened top caddy on top of a medication cart outside room [ROOM NUMBER] on the B Hall that contained 10 insulin pens, two bottles of Lantus insulin, one insulin syringe, one cup of alcohol pads, one cup of lancets, and one glucometer. […]

• No harm, potential for more than minimal, isolatedF637Nov 7, 2024

  Based on interview, record review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a significant change in status assessment (SCSA) Minimum Data Set (MDS) assessment was completed for one of two sampled resident (Resident (R) 4) reviewed for hospice. R4 was admitted to hospice care on 09/16/2024; however, a SCSA MDS had not been completed. The findings include: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10//2024, specified, 03. […]

• No harm, potential for more than minimal, isolatedF756Nov 7, 2024

  Based on interview, record review, and facility policy review, the facility failed to take action after receiving a pharmacy recommendation for one of five sampled residents (Resident (R) 6) reviewed for unnecessary medications. The findings include: A facility policy titled, Behavior and Psychoactive Medication Protocol, with a review date of 11/2020, revealed Purpose: The facility strives to enhance the Quality of Life and Quality of Care of residents experiencing behavior and receiving psychoactive medications through the Behavior and Psychoactive Medication review process. Each resident shall receive individualized care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. […]