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/yearDeficiencies per year
8
6
4
2
0
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
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed lack of SCSA MDS completion for Resident (R) 4 | |
| Director of Nursing | Director of Nursing | Stated expectation for timely assessments and responding to medication irregularities |
| Administrator | Administrator | Aware of SCSA MDS requirement but unaware MDS Coordinator did not know the rule |
| Pharmacist 7 | Pharmacist | Reported no response to pharmacy recommendations for Resident (R) 6 |
| R6's primary physician | Physician | Stated 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
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Witnessed R2 hit R1 on the cheek and intervened |
| Director of Nursing | Director of Nursing | Interviewed regarding incident response and care plan revision |
| Administrator | Administrator | Interviewed regarding incident and facility response |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan revision responsibilities |
| MDS Coordinator | MDS Coordinator | Interviewed 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
| Name | Title | Context |
|---|---|---|
| Regional Business Office Manager | Regional Business Office Manager | Conducted investigation, provided education, and interviewed during survey |
| Administrator | Administrator | Interviewed regarding discovery and investigation of misappropriation |
| Detective #2 | Lead Investigating Officer | Interviewed regarding law enforcement investigation and expected indictment |
| Former Business Office Manager | Business Office Manager | Former employee who misappropriated resident funds |
| Director of Nursing | Director of Nursing | Provided 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
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in wound care deficiency for failing to cleanse wound and improper infection control |
| Assistant Director of Nursing | Infection Control Nurse | Interviewed regarding wound care policy and staff training |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for wound care and staffing postings |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed regarding staffing posting responsibilities and training |
| Facility Administrator | Administrator | Interviewed regarding staffing posting policies and issues |
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