HILLSIDE MANOR
803 S UNIVERSITY AVE, BEAVER DAM, WI 53916 · CCN 525447
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★★ 5
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- Non profit - Corporation
- Certified beds
- 115
- Avg residents/day
- 51.0
- Phone
- 9208875901
Inspection history vs Wisconsin & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Wisconsin avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-11-14 | 17 | 9.8 | 9.5 | +7.2 worse |
| 2 | 2023-09-07 | 3 | 9.2 | 9.8 | -6.2 better |
| 3 | 2022-06-28 | 1 | 8.3 | 9.3 | -7.3 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Quality of life and care | 3 |
| Resident assessment and care planning | 1 |
| Nursing and physician services | 1 |
| Resident rights | 3 |
| Nutrition and dietary | 3 |
| Pharmacy service | 4 |
| Administration | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 4.10 | 51.4% |
| RN staffing (reported) | 0.96 | 59.1% |
| Total nurse staffing (adjusted) | 4.65 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 1
- Payment denials
- 1
Chain
- Chain
- SANFORD HEALTH GOOD SAMARITAN (PROSPERA)
- Facilities in chain
- 4
- Chain avg overall
- 2.50 / 5
Inspection citations (21)1 immediate jeopardy1 actual harm
- JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-07-21 · Health · corrected 2025-07-22
Immediate jeopardy
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-07-21 · Health · corrected 2025-07-22
Potential for more than minimal harm
- DF0712Ensure that the resident and his/her doctor meet face-to-face at all required visits.2025-07-21 · Health · corrected 2025-07-24
Potential for more than minimal harm
- DF0585Honor 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.2025-06-24 · Health · corrected 2025-07-24
Potential for more than minimal harm
- DF0610Respond appropriately to all alleged violations.2025-06-24 · Health · corrected 2025-07-24
Potential for more than minimal harm
- DF0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-11-14 · Health · corrected 2024-12-31
Actual harm
- DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- DF0758Implement 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.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- DF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- FF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- FF0851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.2024-11-14 · Health · corrected 2024-12-31
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-09-07 · Health · corrected 2023-09-19
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-09-07 · Health · corrected 2023-09-28
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-09-07 · Health · corrected 2023-10-07
Potential for more than minimal harm
- FF0700Try 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.2022-06-28 · Health · corrected 2022-07-20
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| MCHS HOSPITALS INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2019-05-01 |
| MARSHFIELD CLINIC HEALTH SYSTEM INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2019-05-01 |
| SANFORD | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2025-01-01 |
| MCHS HOSPITALS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-05-01 |
| BUSWELL CLEARY, LINDSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-02 |
| MCKUEN, LAURIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-08-23 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-01 |
| MUNSON, JOLYN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-01 |
| OLSON, NICHOLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-01 |
| POPPEN, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-06-12 |
| BALTUS, JOHN | Individual | CORPORATE DIRECTOR | — | 2016-02-04 |
| FERNANDEZ, EDWARD | Individual | CORPORATE DIRECTOR | — | 2023-09-08 |
| HOERNEMAN, BRIAN | Individual | CORPORATE DIRECTOR | — | 2023-09-01 |
| KLEBE, SAMANTHA | Individual | CORPORATE DIRECTOR | — | 2023-09-08 |
| MATHISON, DOUGLAS | Individual | CORPORATE DIRECTOR | — | 2020-12-15 |
| NEWCOMB, EVERETT | Individual | CORPORATE DIRECTOR | — | 2024-09-13 |
| PROCCI, LINDA | Individual | CORPORATE DIRECTOR | — | 2025-01-14 |
| SMITH, DENNIS | Individual | CORPORATE DIRECTOR | — | 2025-01-14 |
| BALTUS, JOHN | Individual | CORPORATE OFFICER | — | 2023-09-08 |
| FERNANDEZ, EDWARD | Individual | CORPORATE OFFICER | — | 2025-01-01 |
| HOERNEMAN, BRIAN | Individual | CORPORATE OFFICER | — | 2023-04-04 |
| KLEBE, SAMANTHA | Individual | CORPORATE OFFICER | — | 2025-01-01 |
| POPPEN, JEFFREY | Individual | CORPORATE OFFICER | — | 2025-06-12 |
Other facilities in BEAVER DAM
| Name | Overall | Beds |
|---|---|---|
| BEAVER DAM HEALTH CARE CENTER | ★☆☆☆☆ | 90 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.