| Hillside Manor | |
| 803 S University Ave, Beaver Dam, Wisconsin 53916 | |
| (920) 887-5901 | |
| Name | Hillside Manor |
|---|---|
| Location | 803 S University Ave, Beaver Dam, Wisconsin |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 115 |
| Occupancy Rate | 48.43% |
| Medicare ID (CCN) | 525447 |
| Legal Business Name | Beaver Dam Community Hospitals Inc. |
| Ownership Type | Non Profit - Corporation |
| Chain | Sanford Health (4 nursing homes) |
| Chain Average Overall Rating | 2.8 out of 5 |
| NPI Number | 1750451142 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Beaver Dam Community Hospitals Inc |
| Doing Business As | Hillside Manor (SNF) |
| Address | 803 S University Ave, Beaver Dam, WI 53916 |
| Phone Number | 920-887-5901 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 3.88 | 3.86 |
| Registered nurse (RN) hours per resident per day | 1.1 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.28 | 0.86 |
| Nurse aide hours per resident per day | 2.5 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.32 | 3.42 |
| RN hours per resident per day on the weekend | 0.64 | 0.48 |
| Physical therapist hours per resident per day | 0.03 | 0.07 |
| Total nursing staff turnover | 50% | 45.8% |
| Registered nurse turnover | 66.7% | 42.9% |
| Number of administrators who have left the nursing home | 1 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 2 |
| Total Amount of Fines in Dollars | $193,352 |
| Number of Payment Denials | 1 |
| Total Number of Penalties | 3 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Mar 12, 2026 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. F0694, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Apr 4, 2026 |
| Mar 12, 2026 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Apr 4, 2026 |
| Jul 21, 2025 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Complaint inspection | Immediate jeopardy, isolated | Corrected by Jul 22, 2025 |
| Jul 21, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Jul 22, 2025 |
| Jul 21, 2025 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. F0712, Nursing and Physician Services, Complaint inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 24, 2025 | 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. F0585, Resident Rights, Complaint inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 24, 2025 | Respond appropriately to all alleged violations. F0610, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Nov 14, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection, Complaint inspection | Actual harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. F0851, Administration, Standard inspection | Potential for harm, widespread | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. F0557, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. F0756, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Ensure 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Nov 14, 2024 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. F0806, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Sep 7, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Sep 28, 2023 |
| Sep 7, 2023 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Sep 19, 2023 |
| Sep 7, 2023 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Oct 7, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.28 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 8.16 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.13 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 5.39 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 1.9 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.18 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.29 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.51 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.46 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.26 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.25 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 3.1 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.13 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.32 | 15.38 |
Beaver Dam Health Care Center Location: 410 Roedl Ct., Beaver Dam, Wisconsin 53916 Phone: (920) 887-7191 |