Tj Samson Community Hospital

Total Number of Beds: 16	Percent of Occupied Beds: 94%
Total Number of Residents: 15	Located Within a Hospital: Yes
Type of Ownership: Non profit - Other	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: None	Medicare/Medicaid: Participating in Medicare Only
* Details Last Reported on: 12/01/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 2.13

Number of LPN/LVN Hours per Nursing Home Resident per Day: 4.19

Number of CNA Hours per Nursing Home Resident per Day: 1.68

Number of Staff Hours per Nursing Home Resident per Day: 8

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 8%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 27%
Percent of Short-Stay Residents With Delirium: 0%
** Details Last Reported on: 12/1/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2002-05-14	2002-05-14	Mistreatment Deficiencies	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Pattern	Minimal harm or potential for actual harm
2002-05-14	2002-05-14	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
2002-05-14	2002-06-14	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2003-02-26	2003-02-28	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
2003-12-01	2004-01-02	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
2003-12-01	2004-01-05	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
2003-12-01	2004-01-05	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.