Cycle 1
Health 2025-06-23 · Fire 2025-06-23
23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Jefferson, WI
Alden Estates Of Countryside, Inc
1-star overall rating with 1-star inspections with $114,395 in total fines with 23 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1130 Collins Road, Jefferson, WI
(920) 674-3170
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Alden Network
Operator or chain grouping
Approved since
1978-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
27 facilities
Chain averages 2 overall / 3 health / 1 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,919
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.82
Baseline 14.08% · Performance 18.73% · Measure score 5.82 · Achievement 5.82 · Improvement 0
Healthcare-associated infections
4.56
Baseline 4.93% · Performance 6.47% · Measure score 4.56 · Achievement 4.56 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.76 hours · Performance 2.79 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.99% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 194 · Observed rate 6.7% · Lower 95% interval 6.59% |
| Discharge to community | 48.77% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 165 · Observed rate 45.45% · Lower 95% interval 41.91% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 62.32% |
95.27%
32.9 pts worse
|
Numerator 86 · Denominator 138 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 138 |
| Discharge self-care score | 60.67% |
53.69%
7 pts better
|
Numerator 54 · Denominator 89 |
| Discharge mobility score | 58.43% |
50.94%
7.5 pts better
|
Numerator 52 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 3.62% |
2.29%
1.3 pts worse
|
Numerator 5 · Denominator 138 · Adjusted rate 3.21% |
| Healthcare-associated infections requiring hospitalization | 6.47% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 4.88% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | 3.82% |
42%
38.2 pts worse
|
Numerator 6 · Denominator 157 |
| Discharge function score | 70.79% |
56.45%
14.3 pts better
|
Numerator 63 · Denominator 89 |
| Transfer of health information to provider | 73.68% |
95.95%
22.3 pts worse
|
Numerator 28 · Denominator 38 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 60 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 28.36% |
25.2%
3.2 pts better
|
Numerator 19 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.6% |
95.7%
28.1 pts worse
|
93.4%
25.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.1% · Q2 59.8% · Q3 74.7% · Q4 62.6% · 4Q avg 67.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.0% |
95.0%
13 pts worse
|
95.5%
13.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.2%
1.2 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.4% · Q3 3.3% · Q4 3.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
5.0%
2.2 pts worse
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.9% · Q3 9.9% · Q4 6.1% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.9%
0.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.8% · Q3 4.6% · Q4 4.5% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
16.6%
1.2 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 16.0% · Q3 16.7% · Q4 16.4% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
16.7%
0.6 pts worse
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.0% · Q3 17.0% · Q4 14.3% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.0% |
21.1%
7.1 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 12.1% · Q3 18.1% · Q4 10.1% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
17.3%
7.5 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 11.1% · Q3 16.1% · Q4 4.7% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
2.3%
0.6 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.4% · Q3 4.3% · Q4 1.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.0%
1.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
25.5%
4.5 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 40.5% · Q3 26.5% · Q4 28.6% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.5%
1.1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.1% · Q3 6.7% · Q4 3.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.4% |
86.8%
37.4 pts worse
|
81.7%
32.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.3% · Q2 47.1% · Q3 54.1% · Q4 41.5% · 4Q avg 49.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
15.0%
6.2 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 8.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
82.2%
32.2 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
22.7%
3.8 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 17.9% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-27 · Fire 2024-03-27
19 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-12-05 · Fire 2022-12-05
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-07-18
F · Potential for more than minimal harm
2025-06-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-07-14
F · Potential for more than minimal harm
2025-06-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-06-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-23
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-06-23
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-14
F · Potential for more than minimal harm
2024-03-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-14
F · Potential for more than minimal harm
2024-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-03-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-03-27
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-03-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-27
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2024-04-08
F · Potential for more than minimal harm
2022-12-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-02
F · Potential for more than minimal harm
2022-12-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-12-19
E · Potential for more than minimal harm
2022-12-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
G · Actual harm
2025-11-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-22
J · Immediate jeopardy
2025-06-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-06-23
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-23
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-07-07
J · Immediate jeopardy
2025-04-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-12
G · Actual harm
2025-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-04-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-14
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-05-12
G · Actual harm
2024-12-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-12-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-12-03
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-03
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-13
J · Immediate jeopardy
2024-03-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-28
J · Immediate jeopardy
2024-03-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-28
J · Immediate jeopardy
2024-03-27
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-03-28
G · Actual harm
2024-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-16
F · Potential for more than minimal harm
2024-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-03-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-27
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-27
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-04-16
C · Minimal harm
2024-03-27
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-04-16
E · Potential for more than minimal harm
2023-12-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-12-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-10-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-14
G · Actual harm
2022-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-28
Penalties and ownership
What sits behind the stars
$0
2025-06-23
Payment Denial
Payment Denial · denial start 2025-07-08 · 10 days
10 day denial
$51,150
2024-12-03
Fine
Fine · fine $51,150
Fine
$63,245
2024-03-27
Fine
Fine · fine $63,245
Fine
Ownership
The Alden Group, Ltd.
5% Or Greater Direct Ownership Interest · Organization
Alden Management Services, Inc.
Operational/Managerial Control · Organization
Bodalski, Gerard
W-2 Managing Employee · Individual
Carl, Joan
Corporate Director · Individual
Carl, Joan
Corporate Officer · Individual
Davis, Esther
Operational/Managerial Control · Individual
Elisco, Arin
5% Or Greater Indirect Ownership Interest · Individual
Elisco, Audra
5% Or Greater Indirect Ownership Interest · Individual
Elisco, Charles
5% Or Greater Indirect Ownership Interest · Individual
Magnusson, Garrett
5% Or Greater Indirect Ownership Interest · Individual
Magnusson, Lauren
5% Or Greater Indirect Ownership Interest · Individual
Magnusson, Paige
5% Or Greater Indirect Ownership Interest · Individual
Molitor, Robert
Operational/Managerial Control · Individual
Schlossberg, Floyd
Corporate Director · Individual
Schlossberg, Floyd
Corporate Officer · Individual
Schullo, Joseph
5% Or Greater Indirect Ownership Interest · Individual
Schullo, Nicole
5% Or Greater Indirect Ownership Interest · Individual
Schullo, Randi
5% Or Greater Indirect Ownership Interest · Individual
Schullo, Randi
Corporate Officer · Individual
The Floyd A. Schlossberg Living Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Rock River Nursing & Rehab
Fort Atkinson, WI
0-star overall rating with 0-star inspections with Special Focus status with $136,384 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Lake Mills Health Services
Lake Mills, WI
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Watertown Health Care Center
Watertown, WI
1-star overall rating with 1-star inspections with $276,120 in total fines with 20 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
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