Hillside Manor
803 S University Ave, Beaver Dam, WI 53916
Hillside Manor is a nursing home in Beaver Dam, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (920) 887-5901
- Last standard health inspection
- March 12, 2026 (7 months ago)
- Certified beds
- 115
- Residents per day, on average
- 50.7
- Ownership type
- Non profit - Corporation
- Legal business name
- Beaver Dam Community Hospitals INC.
- Chain
- Sanford Health
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (29 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Fine
CMS changed the fine from June 24, 2025 from $227,895 to $148,132.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Ownership
CMS lists this home under a new chain.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
9 citations
Health inspection on March 12, 2026
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
63 of 323 Wisconsin homes (20%) got a citation at the actual harm level in 2026.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 4, 2026.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 4, 2026.
CMS has cited this home for F0812 3 times since 2023.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on April 4, 2026.
CMS has cited this home for F0759 2 times since 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 4, 2026.
CMS has cited this home for F0580 2 times since 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 4, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 4, 2026.
CMS has cited this home for F0689 3 times since 2024.
Citation F0694. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on April 4, 2026.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on April 4, 2026.
CMS has cited this home for F0804 2 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 4, 2026.
CMS has cited this home for F0880 2 times since 2023.
Fine
March 12, 2026 (7 months ago)
CMS fine of $45,220 on March 12, 2026.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Ownership
CMS lists this home under a new chain.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 5 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.1 to 2.5 hours per resident per day.
3 citations
Health inspection on July 21, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 22, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 22, 2025.
Citation F0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS lists it as corrected on July 24, 2025.
2 citations
Health inspection on June 24, 2025
CMS lists this as a complaint inspection.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 24, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on July 24, 2025.
Fine
June 24, 2025 (1 year ago)
CMS fine of $148,132 on June 24, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 26, 2025
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 5 of 5.
Payment stopped
December 11, 2024 (1 year ago)
CMS stopped payment for new admissions from December 11, 2024, for 20 days.
12 citations
Health inspection on November 14, 2024
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 31, 2024.
Citation F0804. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on December 31, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 31, 2024.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on December 31, 2024.
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on December 31, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on December 31, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 31, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on December 31, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 31, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on December 31, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 31, 2024.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on December 31, 2024.
4 citations
Fire safety inspection on November 14, 2024
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on December 31, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 31, 2024.
CMS has cited this home for K0712 2 times since 2023.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on December 31, 2024.
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on November 19, 2024.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.7 to 1.3 hours per resident per day.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.6 to 3.7 hours per resident per day.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
3 citations
Health inspection on September 7, 2023
CMS lists this as a standard inspection.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 28, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 19, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 7, 2023.
4 citations
Fire safety inspection on September 7, 2023
CMS lists this as a standard inspection.
Citation K0225. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on October 2, 2023.
Citation K0131. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for sections of health care facilities separated by fire resistive construction.
CMS lists it as corrected on September 8, 2023.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on September 22, 2023.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 27, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- MCHS HOSPITALS INC5% or greater direct ownership interest · 100% · since 05/01/2019
- MARSHFIELD CLINIC HEALTH SYSTEM INC5% or greater indirect ownership interest · no percentage provided · since 05/01/2019
- SANFORD5% or greater indirect ownership interest · no percentage provided · since 01/01/2025
- MCHS HOSPITALS INCOperational/managerial control · not applicable · since 05/01/2019
- BUSWELL CLEARY, LINDSEYOperational/managerial control · not applicable · since 12/02/2023
- MCKUEN, LAURIEOperational/managerial control · not applicable · since 08/23/2024
- MORRISON, TONYOperational/managerial control · not applicable · since 01/01/2025
- MUNSON, JOLYNOperational/managerial control · not applicable · since 01/01/2025
- OLSON, NICHOLASOperational/managerial control · not applicable · since 01/01/2025
- POPPEN, JEFFREYOperational/managerial control · not applicable · since 06/12/2025
Questions
When was Hillside Manor last inspected?
CMS lists March 12, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Hillside Manor have?
CMS lists 29 health citations since September 7, 2023. CMS also calls these deficiencies.
Has Hillside Manor been fined?
CMS lists 2 fines in the past three years, $193,352 in total.
What is the CMS star rating of Hillside Manor?
Its CMS overall star rating is 2 of 5.
Is Hillside Manor a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.