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Bowling Green Health & Rehabilitation Center

120 Anderson Avenue, Bowling Green, VA 22427 · Caroline County · (804) 633-4839

120 certified beds, about 113 residents a day · For profit - Individual · Medicare and Medicaid since 1995

Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
3 of 5
Staffing
1 of 5
Quality measures
5 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 495297 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on March 28, 2024, inspectors cited 8 health deficiencies (the Virginia average is 14.3, the national average 9.2).

Of 53 health citations since February 2020, 1 was rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $8,278 in the last three years; the largest was $8,278, and the latest is dated May 29, 2025.

Nurses and nurse aides worked 3.38 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.49 of those hours.

44.0% of nursing staff left within the year CMS measured (Virginia average 48.1%).

CMS links it to Lifeworks Rehab, an affiliated group of 64 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 53 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
31D
20E
0F
Potential for minimal harm
0A
0B
1C
May 29, 2025Complaint inspection · 5 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased 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.
  2. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on observation, interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of 12 residents in the survey sample, Resident #10.
  3. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide nutritional care and services consistent with a resident's comprehensive plan of care for one of 12 residents in the survey sample, Resident #12.
  4. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 12 residents in the survey sample, Resident #9.
  5. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to follow infection control practices during ADL (activities of daily living) care for one of 12 residents in the survey sample, Resident #4.
March 6, 2025Complaint inspection · 5 citations
  1. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 21, 2025
    Inspectors wroteBased 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.
  2. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 21, 2025
    Inspectors wroteBased 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.
  3. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 21, 2025
    Inspectors wroteBased 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.
  4. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 21, 2025
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for one of five residents in the survey sample, Resident #4.
  5. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 21, 2025
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the care plan for one of five residents in the survey sample, Resident #3.
March 28, 2024Standard inspection, Complaint inspection · 9 citations
  1. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store food in a sanitary manner in one of one kitchen.
  2. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide notification to the responsible party of a change in resident treatment for one of 33 residents in the survey sample, Resident #309.
  3. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a pressure injury for one of 33 residents in the survey sample, Resident #97.
  4. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide urinary catheter care and services for one of 33 residents in the survey sample, Resident #97.
  5. D
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    F691 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide urostomy care and services for one of 33 residents in the survey sample, Resident #259.
  6. D
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    F745 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide medically related social services to maintain the highest practicable physical, mental and psychosocial well-being for two of 33 residents in the survey sample, Residents #86 and #62.
  7. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for one of 33 residents, Resident #15.
  8. D
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    F909 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for three of 33 residents in the survey sample, Residents #15, #38 and #54.
  9. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the required notification, to the Ombudsman, for a facility-initiated transfer for one of 33 residents in the survey sample, Residents #92 (R92).
April 21, 2022Standard inspection · 10 citations
  1. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow physician's orders for three of 37 residents in the survey sample, Resident # 93 (R93), Resident #15 (R15) and Resident #75 (R75). The facility staff failed to monitor a fluid restriction for R93; and failed to provide care and services for a central venous access (central line) for R15 and R75.
  2. E
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow the menu for one of 37 residents in the survey sample, Resident #309; and for the dinner meal on 4/19/22.
  3. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to store food in a sanitary manner in one of two refrigerators in the main kitchen.
  4. E
    Dispose of garbage and refuse properly.
    F814 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on observation and staff interview, the facility staff failed to maintain one of one dumpsters in a sanitary manner.
  5. D
    Honor the resident's right to manage his or her financial affairs.
    F567 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on resident interview, facility document review and clinical record review, the facility staff failed to allow one of 37 residents in the survey sample to withdraw more than twenty dollars from their personal fund account at a time, Resident #99 (R99).
  6. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for 2 of 37 residents in the survey sample, Residents #33 and #97. The facility staff failed to administer oxygen to Resident #33 (R33) per the physician prescribed rate of three liters per minute. The facility staff failed to store a nebulizer mask in a sanitary manner for Resident # 97 (R97).
  7. D
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on staff interview, facility document review and employee record review, the facility staff failed to perform annual performance evaluations on two of five CNA (certified nursing assistant) record reviews.
  8. D
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    F806 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to honor a resident's preferences for one of 37 residents in the survey sample, Resident #309 (R309).
  9. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement infection control practices for one of nine residents during the medication administration observation, Resident #105. The facility staff failed to administer oral medication to Resident #105 (R105) in a sanitary manner.
  10. C
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    F727 · Nursing and Physician Services · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) May 18, 2022
    Inspectors wroteBased on staff interview and facility document review, the facility staff failed to have an registered nurse (RN), other than the director of nursing, on duty on 4/2/2022.
February 13, 2020Standard inspection · 24 citations
  1. E
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on resident interview, facility document review and clinical record review, it was determined the facility staff failed to meet the requirements for advanced directives for four of 59 residents in the survey sample, (Residents #24, #116, # 84, and #40). The facility staff failed to obtain a copy of Resident #24's Appointment of Agent to Make Healthcare Decision as documented on the resident's admission paperwork. The facility staff failed to periodically review, Resident 116's, Resident #84's and Resident #40's decisions regarding advance directives.
  2. E
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wrote4. Resident #89 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: dementia, quadriplegia (Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause.) (1), diabetes, gastrointestinal bleed, and high blood pressure. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/14/2020 coded the resident as unable to answer the question for the BIMS and had both short and long-term memory difficulties. [...]
  3. E
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wrote3. Resident #89 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: dementia, quadriplegia (Paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury. Trauma is the usual cause.) (1), diabetes, gastrointestinal bleed, and high blood pressure. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/14/2020 coded the resident as unable to answer the question for the BIMS (brief interview for mental status) and had both short and long-term memory difficulties. [...]
  4. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to develop and/or implement the comprehensive care plan for five of 59 residents in the survey sample, (Residents #4, #40, #15, #62, and #61). The facility staff failed to implement the comprehensive care plan to offer non-pharmacological interventions prior to the administration of pain medication for Resident #4, failed to develop a comprehensive care plan to address Resident #40's PICC (peripherally inserted central catheter) and failed to implement Resident #40's comprehensive care plan for palm guards. The facility staff failed to develop a comprehensive care plan to address the care of Resident #15's PICC. [...]
  5. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for eight of 59 residents in the survey sample, Resident #24, #4, #25, #31, #28, #21, #13 and #38.
  6. E
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice to clarify physician orders for two of 59 residents in the survey sample, Residents #111 and Resident #23. The facility staff failed to clarify a physician order for Lorazepam for Resident #23, which lead to the resident receiving more than double the prescribed dose of medication. The facility staff failed to clarify physician orders for multiple as needed pain medications for Resident #23 to determine which and when each medication should be administered.
  7. E
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    F694 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services consistent with professional standards of practice and in accordance with physician orders for two of 59 residents in the survey sample with a central venous access, (Residents #40 and #15). Resident #40 had a PICC (peripherally inserted central catheter) (1) in place in her right arm during the time of the survey. There were no orders or documentation for the maintenance and care of the PICC. The dressing on the PICC was dated 1/29/2020, and had not been changed in 14 days. Resident #15 had a PICC in place in her right arm during the time of the survey. The dressing on the PICC was dated 1/30/2020; the dressing had not been changed in 13 days.
  8. E
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    F700 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for eight of 59 residents in the survey sample, (Residents #267, #21, #24, #116, #55, #8, #317 and #320). The facility staff failed to review risks and benefits, failed to obtain informed consent for the use of bed rails and failed to evidence that appropriate alternatives were attempted prior to the resident's use of bed rails for Resident #267, Resident #21, Resident #24, Resident #116, Resident #55, Resident #8, Resident #317 and Resident #320.
  9. E
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a resident was free of unnecessary psychotropic medications for one of 59 residents in the survey sample, Resident #111. Based on the comprehensive assessment the facility staff failed to ensure duplicate antianxiety medication was not administered to Resident #111.
  10. E
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #111) of 59 sampled residents was free of a significant medication errors. The facility staff administered both Lorazepam tablet (1 mg) twice daily and Lorazepam concentrate three times a day resulting in Resident #111 receiving a total of two milligrams of Lorazepam per day from 2/1/2020 through 2/7/2020, and a total of 5 mg per day, from 2/8/2020 through 2/12/2020.
  11. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature. The facility staff failed to provide food at a palatable temperature during lunch on 2/12/20.
  12. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for three of 59 residents in the survey sample, (Residents #40, #15, and #318); and in one of two dining rooms, (Dining Room B); and in two of 62 resident rooms, (Rooms #35 and #36). The facility staff failed to ensure PICC (peripherally inserted central catheter) care was provided including dressing changes, to prevent infection for Resident #40 who had a PICC in place in her right arm, and Resident #15, who had a PICC in place in her right arm. The facility staff failed to store Resident #318's nebulizer mask with a protective covering, to prevent infection on 2/12/2020. [...]
  13. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure three of 59 sampled residents, (Residents #25, #21 and #13) were free from abuse. On 11/15/18, Resident #25 was hit in the chest by Resident #31. On 12/22/19, Resident #21 was hit in the face by Resident #28 and on 7/5/19, Resident #38 was observed with his hand inside Resident #13's brief and was caressing Resident #13's buttocks.
  14. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wrote2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions An interview was conducted with Resident #24 on 2/11/2020 at 4:58 p.m. When asked if anyone had ever cursed at her, hit her or abused her, Resident #24 stated that the gentleman across the hall from her (Resident #41) called her a bitch. Resident #24 stated she had reported it. [...]
  15. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wrote2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke, diabetes, high blood pressure, depression and hemiplegia (paralysis affecting only one side of the body) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was cognitively intact to make daily decisions An interview was conducted with Resident #24 on 2/11/2020 at 4:58 p.m. When asked if anyone had ever cursed at her, hit her or abused her, Resident #24 stated that the gentleman across the hall from her (Resident #41) called her a bitch. Resident #24 stated she had reported it. [...]
  16. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence written notification was provided or sent to the resident and/or responsible party regarding the reasons for a transfer to the hospital for three of fifty nine residents in the survey sample, (Residents #74, #89 and #66). The facility staff failed to evidence written notification was provided to Resident #74 or the responsible party (RP) for the residents 12/12/19, hospital transfer, failed to evidence written notification to Resident #89 or the RP for the residents 12/27/29 hospital transfer and to Resident #66 or the RP for the residents 12/20/19 hospital transfer.
  17. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for one of 59 residents in the survey sample, Resident #318. The facility staff failed to develop a baseline care plan for Resident #318's physician-ordered TED (thromboembolic-deterrent) hose.
  18. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide treatment and care in accordance with professional standards of practice and the plan of care for one of 59 residents in the survey sample, Resident #318. The facility staff failed to apply TED (thromboembolism deterrent) hose to Resident #318's on 2/12/2020, as ordered by the physician.
  19. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries, and to promote healing of a pressure injury for two of 59 residents in the survey sample, Residents #267 and #40. The facility staff failed to assess Resident #267's pressure injuries from 1/16/20 until 2/11/20. The facility staff failed to ensure Bilateral palm guards were in place for Resident #40, per the comprehensive plan of care.
  20. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide respiratory care consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 59 residents in the survey sample, Resident #318. The facility staff failed to store a nebulizer mask with a protective covering for Resident #318 on 2/12/2020.
  21. D
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence a complete pain management program for one of fifty nine residents in the survey sample, Residents #23 and Resident #4. The facility staff failed to document the location of pain, pain scale and if any non-pharmacological interventions were provided prior to the administration of a narcotic pain medication for Resident #4.
  22. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on resident interview, staff interview and clinical record review, it was determined the facility staff failed to ensure a drug regimen free of unnecessary medications for one of 59 residents in the survey sample, (Resident #4). The facility staff administered a physician prescribed as needed narcotic pain medication to Resident #4 for a pain level rating of zero and failed to document non-pharmacological interventions attempted prior to administering the as needed pain medication on 1/13/2020 and 2/9/2020.
  23. D
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a safe and sanitary manner. The facility staff failed to store milk in a safe manner in the A unit nourishment room. Two eight ounce cartons of skim milk with a sell by date of 2/4/20 was observed in the refrigerator.
  24. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 23, 2020
    Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for two of 59 residents in the survey sample, Residents #25 and #21. Resident #31 hit Resident #25 in the chest on 11/15/18 and Resident #28 hit Resident #21 in the face on 12/22/19. The facility staff failed to document these incidents in Resident #25's and Resident #21's clinical records.

Fire safety inspections

13 fire safety citations on file: 7 on April 21, 2022, 6 on February 13, 2020.

Every fire safety citation13 citations
  1. D
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · April 21, 2022 · Corrected (the home has a date of correction)
  2. D
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · April 21, 2022 · Corrected (the home has a date of correction)
  3. D
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · April 21, 2022 · Corrected (the home has a date of correction)
  4. D
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · April 21, 2022 · Corrected (the home has a date of correction)
  5. D
    Have proper power supply for life support equipment.
    K 915 · April 21, 2022 · Corrected (the home has a date of correction)
  6. D
    Have a battery powered remote alarm panel in a location accessible by operating personnel.
    K 916 · April 21, 2022 · Corrected (the home has a date of correction)
  7. C
    Establish staff and initial training requirements.
    E 37 · April 21, 2022 · Corrected (the home has a date of correction)
  8. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 13, 2020 · Corrected (the home has a date of correction)
  9. F
    Install corridor and hallway doors that block smoke.
    K 363 · February 13, 2020 · Corrected (the home has a date of correction)
  10. D
    Install proper backup exit lighting.
    K 281 · February 13, 2020 · Corrected (the home has a date of correction)
  11. D
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · February 13, 2020 · Corrected (the home has a date of correction)
  12. D
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · February 13, 2020 · Corrected (the home has a date of correction)
  13. D
    Ensure proper usage of power strips and extension cords.
    K 920 · February 13, 2020 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
May 29, 2025Fine $8,278

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeVirginiaUnited States
All nursing staff (RN, LPN and aides)3.383.763.86
Registered nurses0.490.690.69
All nursing staff on weekends3.003.293.42
Nurse aides1.91
Licensed practical nurses0.98
Nursing staff turnover (share who left in a year)44.0%48.1%45.8%
Registered nurse turnover50.0%48.2%42.9%
Administrators who left1

CMS expects 4.69 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.54 on weekdays and 3.00 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.32 in April to June 2025 to 3.38 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.380.493.543.00 0.0%0 of 90113
Oct to Dec 20253.200.393.352.81 0.0%0 of 92113
Jul to Sep 20253.060.443.232.62 0.0%0 of 92111
Apr to Jun 20253.320.333.512.84 0.0%0 of 91110
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Virginia, Jan to Mar 20263.580.563.763.125.7%0.2% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Virginia

JobMedianMiddle halfEmployed
Virginia, all employers
CNAs (nursing assistants)$20.77$17.80 to $22.5640,580
LPNs and LVNs$31.21$28.66 to $35.8415,550
Registered nurses$45.00$38.51 to $49.5377,490
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For Bowling Green Health & Rehabilitation Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeVirginiaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
11.814.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.31.61.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.53.63.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.61.31.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
15.615.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
1.34.74.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
8.014.215.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
31.122.323.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
11.411.512.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.61.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.81.51.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Bowling Green Health & Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (59.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

59.7% this home

Better than the national rate

US median of homes 51.5% · Virginia: 101 better, 22 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 165 eligible stays.

Potentially preventable readmissions

11.9% this home

No different from the national rate

US median of homes 10.7% · Virginia: 1 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 147 eligible stays.

Infections that led to a hospital stay

5.2% this home

No different from the national rate

US median of homes 7.1% · Virginia: 2 better, 8 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 93 eligible stays.

Self-care and mobility at discharge

56.8% this home

Median of homes: Virginia60.0% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 81 residents counted.

Falls with major injury

0.0% this home

Median of homes: Virginia0.7% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 113 residents counted.

New or worsened pressure ulcers

0.7% this home

Median of homes: Virginia2.1% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 113 residents counted.

Medication list given at discharge

95.2% this home

Median of homes: Virginia97.8% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 21 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: BOWLING GREEN SNF LLC. CMS links this home to Lifeworks Rehab, a group of 64 nursing homes averaging 2.1 stars overall.

NameRoleTypeShareSince
Bowling Green Holdings I LLC5% or greater indirect ownership interestOrganization05/28/2021
Charles 1994 Family Grantor Trust5% or greater indirect ownership interestOrganization05/28/2021
Edward 1998 Family Grantor Trust5% or greater indirect ownership interestOrganization05/28/2021
Ek 2005 Family Trust5% or greater indirect ownership interestOrganization05/28/2021
Fay 2014 Family Grantor Trust5% or greater indirect ownership interestOrganization05/28/2021
Fay 2014 LLC5% or greater indirect ownership interestOrganization05/28/2021
Ll 2013 Family Trust5% or greater indirect ownership interestOrganization05/28/2021
Mms 2008 Family Trust5% or greater indirect ownership interestOrganization05/28/2021
Mzr East LLC5% or greater indirect ownership interestOrganization05/28/2021
Saul 2012 Family Grantor Trust5% or greater indirect ownership interestOrganization05/28/2021
Silverstone East LLC5% or greater indirect ownership interestOrganization05/28/2021
Sol 2000 Family Grantor Trust5% or greater indirect ownership interestOrganization05/28/2021
Sol 2000 LLC5% or greater indirect ownership interestOrganization05/28/2021
Stevens 3920 & Family LLC5% or greater indirect ownership interestOrganization05/28/2021
Stevens 3920 Family Grantor Trust5% or greater indirect ownership interestOrganization05/28/2021
Stevens 3920 LLC5% or greater indirect ownership interestOrganization05/28/2021
Wood, JaneeneW-2 managing employeeIndividual05/28/2021
Rylbss East Manager LLCOperational/managerial controlOrganization05/28/2021

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 15 problems in this area, most recently on May 29, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
  2. When is the care plan meeting, and can family attend it?Inspectors cited 9 problems in this area, most recently on May 29, 2025: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
  3. Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 9 problems in this area, most recently on March 6, 2025: "Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature."
  4. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on March 28, 2024: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.00 hours per resident per day, below the Virginia average of 3.29.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

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Common questions

What is Bowling Green Health & Rehabilitation Center's Medicare star rating?
CMS rates Bowling Green Health & Rehabilitation Center 3 out of 5 stars overall, with 3 for health inspections, 1 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Bowling Green Health & Rehabilitation Center get at its last inspection?
8 health deficiencies at the standard inspection on March 28, 2024. The Virginia average is 14.3.
Has Bowling Green Health & Rehabilitation Center been fined?
Yes. CMS lists 1 fine totaling $8,278 in the last three years.
Does Bowling Green Health & Rehabilitation Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Bowling Green Health & Rehabilitation Center?
CMS lists 18 owners and managers, and links the home to Lifeworks Rehab. Legal business name: BOWLING GREEN SNF LLC.

Sources

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