Countryside Estates, Inc.

Total Number of Beds: 111	Percent of Occupied Beds: 57%
Total Number of Residents: 63	Located Within a Hospital: No
Type of Ownership: For profit - Partnership	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: None	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 10/30/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.13

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.47

Number of CNA Hours per Nursing Home Resident per Day: 2.53

Number of Staff Hours per Nursing Home Resident per Day: 3.13

Nursing Home Resident Information**:

** Details Last Reported on: 10/30/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-09-13	2001-11-15	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Potential for minimal harm
2001-09-13	2001-11-15	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
2001-09-13	2001-11-15	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
2001-09-13	2001-11-15	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
2001-09-13	2001-11-15	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2001-09-13	2001-11-15	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
2001-09-13	2001-11-15	Nutrition and Dietary Deficiencies	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
2001-09-13	2001-11-15	Administration Deficiencies	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
2001-09-13	2001-11-15	Administration Deficiencies	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
2003-10-30	2003-12-14	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
2003-10-30	2003-12-14	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.	Isolated	Minimal harm or potential for actual harm
2003-10-30	2003-12-14	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
2003-10-30	2003-12-14	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2003-10-30	2003-12-14	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
2003-10-30	2003-12-14	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
2003-10-30	2003-12-14	Environmental Deficiencies	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
2003-10-30	2003-12-14	Administration Deficiencies	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm

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