Inspection Reports for
Thomson-Hood Veterans Center

100 VETERANS DRIVE, WILMORE, KY, 40390

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 2.7 deficiencies/year

Deficiencies are regulatory findings recorded during state inspections.

43% better than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

4 3 2 1 0
2018
2019
2025

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Mar 27, 2025

Visit Reason
The inspection was conducted to investigate a complaint regarding resident-to-resident abuse and to assess food service quality and food storage safety at the facility.

Complaint Details
The complaint investigation focused on an incident on 02/14/2025 where Resident R117 entered Resident R134's room and struck him, causing injury. The facility's investigation confirmed the incident and identified failures in supervision and prevention of resident-to-resident abuse.
Findings
The facility failed to protect residents from abuse when one resident struck another causing injury. Additionally, the facility failed to provide palatable, timely meals and failed to store food safely in nourishment rooms, with issues including cold food temperatures, unpalatable meals, and unlabeled or undated food in refrigerators.

Deficiencies (3)
F 0600: The facility failed to protect residents from abuse when Resident R117 struck Resident R134 causing a laceration requiring hospital evaluation and closure with steri-strips. The facility lacked adequate supervision and monitoring of wandering residents to prevent altercations.
F 0804: The facility failed to provide residents with palatable foods served at safe and appetizing temperatures. Observations revealed hot foods served between 90 and 110 degrees Fahrenheit, which is below the USDA recommended 140 degrees F, and residents reported cold, overcooked, and unappetizing meals with inconsistent meal service times.
F 0812: The facility failed to store food safely in nourishment rooms on three units, with observations of unlabeled, undated food items and unclean refrigerators, increasing the risk of cross-contamination.
Report Facts
Temperature of hot foods: 90 Temperature of hot foods: 110 BIMS score: 4 BIMS score: 8 Dates of admission: Apr 10, 2024 Dates of admission: Dec 5, 2024

Employees mentioned
NameTitleContext
Nurse Shift Program Supervisor Assessed Resident R117 after altercation and coordinated hospital evaluation
Nurse Aide State Registered (NASR14) Witnessed and assisted during altercation between residents R117 and R134
Registered Nurse (RN) House Supervisor Responded to altercation and assessed Resident R134
Unit Manager Provided information on wandering resident supervision policies
Director of Nursing (DON) Discussed expectations for supervision and prevention of resident-to-resident altercations
Administrator Provided expectations on resident freedom of movement and supervision
Prep Center Coordinator Assisted with test trays and temperature checks of food service
Cook One Described breakfast tray line setup and food preparation
Food Service Operations Manager Discussed food temperature expectations and nourishment room responsibilities
Registered Nurse (RN) Manager Discussed expectations for food temperature and meal quality

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Sep 5, 2019

Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to treat a resident with respect, dignity, and privacy during blood glucose monitoring.

Complaint Details
The complaint was substantiated. The investigation found that Licensed Practical Nurse (LPN) #9 performed blood glucose testing in a public area without privacy and disclosed results aloud, violating Resident #43's rights.
Findings
The facility failed to provide privacy and dignity to Resident #43 during blood glucose testing by performing the procedure in a public hallway and disclosing results aloud. Staff interviews confirmed lack of training and improper practices violating resident rights.

Deficiencies (1)
F 0550: The facility failed to honor the resident's right to dignity, privacy, and confidentiality by performing blood glucose testing for Resident #43 in a public hallway and disclosing results aloud in front of others.
Report Facts
Residents Affected: 1 Employment Duration: 8 BIMS Score: 11 Resident Sample Size: 36

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN) #9 Named in privacy violation during blood glucose testing
Unit Manager (UM) Provided interview regarding staff expectations and LPN #9's conduct
Staff Development Coordinator (SDC) Provided interview about staff training and competencies
Director of Nursing (DON) Provided interview about expectations for resident care and privacy
Administrator Provided interview about facility expectations for dignity and care

Inspection Report

Annual Inspection
Deficiencies: 4 Date: Dec 6, 2018

Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.

Findings
The facility was found deficient in multiple areas including failure to notify the physician of elevated blood glucose levels for a diabetic resident, failure to develop and revise comprehensive care plans for residents with specific needs, and improper storage and handling of food items in nourishment refrigerators.

Deficiencies (4)
F 0580: The facility failed to notify the Medical Provider when Resident #114 had blood glucose levels above 400 on 11/16/18 and 11/18/18, contrary to facility policy requiring notification via secure communication.
F 0657: The facility failed to develop and revise comprehensive care plans for two residents, including Resident #35 who refused care and Resident #114 with hyperglycemia, lacking documented interventions to address these issues.
F 0684: The facility failed to provide appropriate treatment and care to Resident #114 by not marking elevated blood glucose levels in the documentation system to notify the physician for timely medication adjustments.
F 0812: The facility failed to store and distribute food safely; nourishment refrigerators contained unlabeled, undated, and expired food items, violating facility policies on food storage and safety.
Report Facts
Blood glucose readings: 567 Blood glucose readings: 523 Blood glucose readings: 410 Blood glucose readings: 435 Blood glucose readings: 334 Expired milk cartons: 15 Residents sampled: 31 Residents affected: 1 Residents affected: 2

Employees mentioned
NameTitleContext
Licensed Practical Nurse #1 Licensed Practical Nurse Signed nursing note on 11/18/18 regarding Resident #114's blood glucose readings
Licensed Practical Nurse #2 Licensed Practical Nurse Interviewed regarding Resident #114's blood glucose levels and notification process
Roosevelt Unit Manager Unit Manager Interviewed about notification expectations for high blood glucose levels
Advance Practice Registered Nurse APRN Runs daily report for elevated glucose levels and expects notification for levels above 400
Director of Nursing Director of Nursing Interviewed about facility policy and expectations for notification and care plan revisions
Administrator Facility Administrator Interviewed about expectations for staff to follow policies on notification and care plans
Nurse #7 Nurse Interviewed about Resident #35's refusal behaviors and care planning
Unit Manager Unit Manager Interviewed about care plan revisions for Resident #35
Registered Nurse/[NAME] Unit Nurse Manager #3 Registered Nurse/Unit Nurse Manager Interviewed about nourishment refrigerator maintenance and food labeling
Aide #1 Nurse Aide Responsible for ordering and stocking nourishment refrigerators
Aide #2 Nurse Aide Responsible for ordering and rotating food stock in nourishment refrigerators
Aide #3 Nurse Aide Responsible for ordering food items and stocking nourishment refrigerator
Registered Nurse/[NAME] Nurse Manager #4 Registered Nurse/Unit Nurse Manager Interviewed about food stocking and rotation practices

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