Air Force Village I I, Inc.

Total Number of Beds: 8	Percent of Occupied Beds: 75%
Total Number of Residents: 6	Located Within a Hospital: No
Type of Ownership: Non profit - Corporation	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare Only
* Details Last Reported on: 05/02/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day:

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

Number of CNA Hours per Nursing Home Resident per Day:

Number of Staff Hours per Nursing Home Resident per Day:

Nursing Home Resident Information**:

** Details Last Reported on: 5/2/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-04-19	2001-04-20	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.	Isolated	Minimal harm or potential for actual harm
2001-04-19	2001-04-20	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Actual harm
2001-04-19	2001-06-01	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2001-04-19	2001-06-01	Environmental Deficiencies	Get rid of garbage properly.	Widespread	Potential for minimal harm
2001-04-19	2001-06-01	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
2002-05-22	2002-07-05	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
2002-05-22	2002-07-05	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
2002-05-22	2002-07-05	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
2002-05-22	2002-07-05	Pharmacy Service Deficiencies	Provide drugs and related services needed by each resident.	Pattern	Minimal harm or potential for actual harm
2003-05-02	2003-06-13	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
2003-05-02	2003-06-13	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm

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