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38/100Alden Estates of Countryside, Inc Inspection Report, Violations & Safety Grade (JEFFERSON, Wisconsin)
1130 COLLINS ROAD, JEFFERSON, Wisconsin 53549
Phone: 9206743170
CMS Overall:1/5
Overview & Bed Count
Certified Beds
120
Avg Residents/Day
102.3
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Jefferson
Sprinkler Systems
Yes
Special Focus
None
Abuse Citation
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.86 | 0.98 | -0.13 |
| Total Nurse Hours per Resident per Day | 3.86 | 4.25 | -0.38 |
| CMS Staffing Rating | 3/5 | 3.7/5 | - |
| Nursing Staff Turnover | 38.0% | 46.7% | - |
Health Citation History
57 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-05 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
| 2026-06-05 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-12-03 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-11-25 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | G – Actual Harm |
| 2025-06-23 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | J – Immediate Jeopardy |
| 2025-06-23 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-06-23 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2025-06-23 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-06-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-06-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2025-06-23 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-06-23 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D – Moderate Harm Potential |
| 2025-06-23 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2025-06-23 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2025-06-23 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2025-06-23 | Nutrition and Dietary Deficiencies | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D – Moderate Harm Potential |
| 2025-06-23 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-06-23 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2025-06-23 | Infection Control Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-04-14 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J – Immediate Jeopardy |
| 2025-04-14 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-04-14 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2025-04-14 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2025-04-14 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-04-14 | Nursing and Physician Services Deficiencies | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | D – Moderate Harm Potential |
| 2024-12-03 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2024-12-03 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2024-12-03 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | E – Moderate Harm Potential |
| 2024-12-03 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-12-03 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-11-18 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-03-27 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | J – Immediate Jeopardy |
| 2024-03-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-03-27 | Administration Deficiencies | 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. | J – Immediate Jeopardy |
| 2024-03-27 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2024-03-27 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2024-03-27 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | E – Moderate Harm Potential |
| 2024-03-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-03-27 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-03-27 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-03-27 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-03-27 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | D – Moderate Harm Potential |
| 2024-03-27 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-03-27 | Resident Rights Deficiencies | 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. | C – Minimal Harm Potential |
| 2023-12-08 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2023-12-08 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2023-10-27 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2023-10-27 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2023-10-27 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2022-12-05 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
Showing 50 of 57 citations.
Fire Safety Citation History
21 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-06-23 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2025-06-23 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2025-06-23 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-06-23 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-06-23 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2025-06-23 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2025-06-23 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | E – Moderate Harm Potential |
| 2025-06-23 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2025-06-23 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | E – Moderate Harm Potential |
| 2025-06-23 | Construction Deficiencies | Use approved construction type or materials. | D – Moderate Harm Potential |
| 2024-03-27 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-03-27 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-03-27 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2024-03-27 | Egress Deficiencies | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | E – Moderate Harm Potential |
| 2024-03-27 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2024-03-27 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2024-03-27 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-03-27 | Miscellaneous Deficiencies | 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. | E – Moderate Harm Potential |
| 2022-12-05 | Smoke Deficiencies | Install an approved automatic sprinkler system. | F – Moderate Harm Potential |
| 2022-12-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | F – Moderate Harm Potential |
| 2022-12-05 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
Total Penalties & Fines
$397,046
Total Fine Amount (CMS)
5
Number of Fines
6
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-11-25 | Fine | $59,670 | - |
| 2025-06-23 | Fine | $197,769 | - |
| 2025-06-23 | Payment Denial | - | 10 days starting 2025-07-08 |
| 2025-04-14 | Fine | $42,532 | - |
| 2024-12-03 | Fine | $33,830 | - |
| 2024-03-27 | Fine | $63,245 | - |
Verified Helpline
Care & Coverage Review
Researching facilities in JEFFERSON, Wisconsin? Speak with a licensed specialist to review your Medicare or health insurance benefits at no cost.
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Medicare & Benefits Review
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Health Insurance Helpline
(Ages 26–64)
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Free, confidential consultation. We may receive referral compensation.
Verified Helpline
Care & Coverage Review
Researching facilities in JEFFERSON, Wisconsin? Speak with a licensed specialist to review your Medicare or health insurance benefits at no cost.
📞 Call (866) 227-7595
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Free, confidential consultation. We may receive referral compensation.