Nursing Care Index

Bowling Green Health & Rehabilitation Center

Bowling Green, Caroline County, Virginia · CCN 495297 · For-profit (Individual) · part of Lifeworks Rehab (64 facilities, chain average 2.1 stars)

CMS rates Bowling Green Health & Rehabilitation Center 3 of 5 overall as of August 2026. 120 certified beds, 113 residents a day on average. 53 citations on record from the current inspection cycles, 1 involving actual harm; 1 fine totalling $8,278.

On record

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★☆☆ 3 of 5
Health inspections★★★☆☆ 3 of 5
Staffing★☆☆☆☆ 1 of 5
Quality measures★★★★★ 5 of 5
Quality: long-stay / short-stay5 / 4 of 5

Staffing

Total nurse staffing3.38365 hours per resident per day
Registered nurses0.49277 hours per resident per day
Weekend total3.00322 hours per resident per day
Nursing staff turnover44% (registered nurses 50%)
Administrators who left1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2025-05-29
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-06-24
2025-05-29
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-24
2025-05-29
complaint survey
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-24
2025-05-29
complaint survey
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-24
2025-05-29
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-24
2025-03-06
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-21
2025-03-06
complaint survey
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-21
2025-03-06
complaint survey
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-21
2025-03-06
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-21
2025-03-06
complaint survey
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-21
2024-03-28 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-31
2024-03-28
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2024-03-28
complaint survey
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2024-03-28 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2024-03-28 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2024-03-28 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0691
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2024-03-28 Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · tag F0745
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2024-03-28 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2024-03-28 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.
Environmental Deficiencies · tag F0909
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-31
2022-04-21 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-05-18
2022-04-21 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.
Nutrition and Dietary Deficiencies · tag F0803
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-05-18
2022-04-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-05-18
2022-04-21 Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies · tag F0814
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-05-18
2022-04-21 Honor the resident's right to manage his or her financial affairs.
Resident Rights Deficiencies · tag F0567
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-05-18
2022-04-21 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-05-18
2022-04-21 Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · tag F0730
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-05-18
2022-04-21 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies · tag F0806
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-05-18
2022-04-21 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-05-18
2022-04-21 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.
Nursing and Physician Services Deficiencies · tag F0727
C No actual harm, with potential for minimal harm; widespread Deficient, Provider has date of correction
2022-05-18
2020-02-13 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.
Resident Rights Deficiencies · tag F0578
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 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.
Resident Rights Deficiencies · tag F0622
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 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.
Resident Rights Deficiencies · tag F0625
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 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.
Quality of Life and Care Deficiencies · tag F0700
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 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.
Pharmacy Service Deficiencies · tag F0758
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2020-03-23
2020-02-13 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · tag F0655
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23
2020-02-13 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2020-03-23

Fines and payment denials

DatePenaltyAmount
2025-05-29Fine$8,278

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Bowling Green Holdings I LLC
Organization
5% or greater indirect ownership interest2021-05-28
Charles 1994 Family Grantor Trust
Organization
5% or greater indirect ownership interest2021-05-28
Edward 1998 Family Grantor Trust
Organization
5% or greater indirect ownership interest2021-05-28
Ek 2005 Family Trust
Organization
5% or greater indirect ownership interest2021-05-28
Fay 2014 Family Grantor Trust
Organization
5% or greater indirect ownership interest2021-05-28
Fay 2014 LLC
Organization
5% or greater indirect ownership interest2021-05-28
Ll 2013 Family Trust
Organization
5% or greater indirect ownership interest2021-05-28
Mms 2008 Family Trust
Organization
5% or greater indirect ownership interest2021-05-28
Mzr East LLC
Organization
5% or greater indirect ownership interest2021-05-28
Saul 2012 Family Grantor Trust
Organization
5% or greater indirect ownership interest2021-05-28
Silverstone East LLC
Organization
5% or greater indirect ownership interest2021-05-28
Sol 2000 Family Grantor Trust
Organization
5% or greater indirect ownership interest2021-05-28
Sol 2000 LLC
Organization
5% or greater indirect ownership interest2021-05-28
Stevens 3920 & Family LLC
Organization
5% or greater indirect ownership interest2021-05-28
Stevens 3920 Family Grantor Trust
Organization
5% or greater indirect ownership interest2021-05-28
Stevens 3920 LLC
Organization
5% or greater indirect ownership interest2021-05-28
Rylbss East Manager LLC
Organization
operational/managerial control2021-05-28
Wood, Janeene
Individual
w-2 managing employee2021-05-28

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Caroline County.