Inspection Reports for Bowling Green Nursing and Rehabilitation Center

KY

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Inspection Report Summary

The most recent inspection on October 21, 2025, found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections also showed no deficiencies, indicating consistent adherence to regulatory standards. There were no complaint investigations reported in the available records. Enforcement actions such as fines or license suspensions were not listed in the available reports. This pattern suggests the facility has maintained compliance over time.

Deficiencies (last 4 years)

Deficiencies (over 4 years) 2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

57% better than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

4 3 2 1 0
2018
2019
2024
2025

Inspection Report

Abbreviated Survey
Census: 55 Deficiencies: 0 Date: Oct 21, 2025

Visit Reason
An abbreviated survey was conducted to assess compliance with 42 CFR 483 subpart B at Bowling Green Nursing and Rehabilitation Center.

Findings
The facility was found to be in substantial compliance with no deficiencies issued related to KY710712 and KY710714.

Report Facts
Sample Size: 1 Supplemental Residents: 0

Inspection Report

Annual Inspection
Deficiencies: 2 Date: Nov 7, 2024

Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident assessments and medication regimen reviews at Bowling Green Nursing and Rehabilitation Center.

Findings
The facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for a resident admitted to hospice care and failed to take action on pharmacy recommendations regarding psychotropic medication for another resident. Both deficiencies were noted with minimal harm and affected a few residents.

Deficiencies (2)
Failed to ensure a significant change in status assessment (SCSA) Minimum Data Set (MDS) was completed for a resident admitted to hospice care.
Failed to take action after receiving a pharmacy recommendation for unnecessary medications for a resident.
Report Facts
Residents affected: 1 Residents affected: 1 Assessment Reference Date: Aug 21, 2024 Medication dosage: 0.25

Employees mentioned
NameTitleContext
MDS CoordinatorConfirmed lack of SCSA MDS completion for Resident (R) 4
Director of NursingDirector of NursingStated expectation for timely assessments and responding to medication irregularities
AdministratorAdministratorAware of SCSA MDS requirement but unaware MDS Coordinator did not know the rule
Pharmacist 7PharmacistReported no response to pharmacy recommendations for Resident (R) 6
R6's primary physicianPhysicianStated possible miscommunication regarding response to pharmacy recommendation

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Oct 3, 2024

Visit Reason
The inspection was conducted following a complaint investigation regarding an incident where Resident 2 (R2) was witnessed hitting Resident 1 (R1) on the cheek on 09/10/2024.

Complaint Details
The complaint investigation was substantiated based on CNA 1 witnessing R2 hit R1 on the cheek. R1 reported no injury but requested a new roommate. R2 was moved to another room and placed on 15-minute checks for 24 hours. Staff and administration interviews confirmed no prior behavioral issues and no recollection of the incident by the residents involved.
Findings
The facility failed to protect one resident from physical abuse and failed to revise the comprehensive care plan for Resident 2 after the behavioral incident. The investigation confirmed the incident was witnessed by staff, and although no injuries were reported, the care plan was not updated to address the behavioral change.

Deficiencies (2)
Failed to protect a resident from physical abuse when R2 hit R1 on the cheek.
Failed to revise the comprehensive care plan for Resident 2 following a behavioral change after the altercation.
Report Facts
Residents affected: 1 Behavioral checks: 15

Employees mentioned
NameTitleContext
CNA 1Certified Nursing AssistantWitnessed R2 hit R1 on the cheek and intervened
Director of NursingDirector of NursingInterviewed regarding incident response and care plan revision
AdministratorAdministratorInterviewed regarding incident and facility response
Assistant Director of NursingAssistant Director of NursingInterviewed regarding care plan revision responsibilities
MDS CoordinatorMDS CoordinatorInterviewed regarding care plan development and revision

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Feb 29, 2024

Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident funds discovered during a routine request by a resident's family member for funds to pay a bill.

Complaint Details
The complaint investigation found misappropriation of funds by the former Business Office Manager who removed $11,523.80 from Resident #6, $1,861.84 from Resident #10, and $1,354.00 from Resident #11. All funds were reimbursed. The facility cooperated with law enforcement and an indictment was expected. The investigation included interviews with the Administrator, Regional Business Office Manager, and law enforcement.
Findings
The facility failed to protect residents from misappropriation of funds for three of eleven sampled residents. The former Business Office Manager removed funds from resident accounts without authorization, but all missing funds were reimbursed. The facility implemented corrective actions including audits, staff education, and ongoing monitoring.

Deficiencies (1)
Failed to protect residents from misappropriation of funds for three residents (Resident #6, #10, and #11).
Report Facts
Amount missing from Resident #6's account: 11523.8 Amount missing from Resident #10's account: 1861.84 Amount missing from Resident #11's account: 1354 Date of facility investigation initiation: Dec 17, 2021 Date of reimbursement to residents: Aug 24, 2022 Former Business Office Manager employment dates: Hired 2019-02-15, last day 2021-12-10

Employees mentioned
NameTitleContext
Regional Business Office ManagerRegional Business Office ManagerConducted investigation, provided education, and interviewed during survey
AdministratorAdministratorInterviewed regarding discovery and investigation of misappropriation
Detective #2Lead Investigating OfficerInterviewed regarding law enforcement investigation and expected indictment
Former Business Office ManagerBusiness Office ManagerFormer employee who misappropriated resident funds
Director of NursingDirector of NursingProvided staff education on abuse policy and misappropriation

Inspection Report

Deficiencies: 0 Date: Nov 7, 2019

Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Bowling Green Nursing and Rehabilitation Center, summarizing the findings of a regulatory survey completed on 2019-11-07.

Findings
No health deficiencies were found during the inspection.

Inspection Report

Routine
Deficiencies: 3 Date: Aug 14, 2018

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, wound treatment, and staffing information at Bowling Green Nursing and Rehabilitation Center.

Findings
The facility failed to implement a comprehensive person-centered care plan for one resident, failed to provide wound care according to physician orders and care plans, and failed to post accurate and current nurse staffing information daily. Deficiencies involved minimal harm or potential for harm affecting few to many residents.

Deficiencies (3)
Failed to implement a comprehensive person-centered care plan for one resident, including measurable objectives and timely actions.
Failed to provide wound care according to physician orders and comprehensive care plan, including failure to cleanse wounds prior to treatment and improper infection control practices.
Failed to post nurse staffing information daily in a prominent place accessible to residents and visitors; staffing information was not accurate or current.
Report Facts
Residents sampled: 17 Residents affected: 1 Residents affected: 1 Residents affected: Few Residents affected: Many

Employees mentioned
NameTitleContext
RN #1Registered NurseNamed in wound care deficiency for failing to cleanse wound and improper infection control
Assistant Director of NursingInfection Control NurseInterviewed regarding wound care policy and staff training
Director of NursingDirector of Nursing (DON)Interviewed regarding expectations for wound care and staffing postings
Licensed Practical Nurse #1Licensed Practical Nurse (LPN)Interviewed regarding staffing posting responsibilities and training
Facility AdministratorAdministratorInterviewed regarding staffing posting policies and issues

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