Hillside Manor
803 S University Ave, Beaver Dam, WI 53916 · Dodge County · 115 certified beds · avg 56 residents/day · certified since Nov 15, 1989
Part of chain: SANFORD HEALTH (4 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 21, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 12, 2026 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 4, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 14, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 31, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 12, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 12, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 12, 2026 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 21, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 21, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 21, 2025 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · from a complaint |
| Jun 24, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Jun 24, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 14, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 14, 2024 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Nov 14, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 14, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 14, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Sep 7, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 7, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Sep 7, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | E |
| 2024 | 12 | 1 | G ▲ |
| 2025 | 5 | 1 | J ▲ |
| 2026 | 9 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $193,352, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 12, 2026 | Fine | $45,220 |
| Jun 24, 2025 | Fine | $148,132 |
| Nov 14, 2024 | Payment Denial | 20 days from Dec 11, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.47 | 4.29 | 3.95 | top 36% in Wisconsin; top 24% in the U.S. |
| Registered Nurse hours | 1.27 | 1.01 | 0.69 | top 21% in Wisconsin; top 8% in the U.S. |
| Weekend total nurse staffing | 3.83 | 3.84 | 3.50 | top 43% in Wisconsin; top 28% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.64 | 0.68 | 0.48 | top 48% in Wisconsin; top 20% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 46.9 | 45.8 | bottom 42% in Wisconsin; bottom 38% in the U.S. |
| RN turnover (%) | 66.7 | 39.7 | 42.9 | bottom 11% in Wisconsin; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.88, RN 1.10, weekend 3.32. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Marshfield Clinic Health System INC | Organization | 5% or Greater Indirect Ownership Interest | — | 05/01/2019 |
| MCHS Hospitals INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/01/2019 |
| Sanford | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2025 |
| Baltus, John | Individual | Corporate Director | NOT APPLICABLE | 02/04/2016 |
| Baltus, John | Individual | Corporate Officer | NOT APPLICABLE | 09/08/2023 |
| Buswell Cleary, Lindsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/02/2023 |
| Buswell Cleary, Lindsey | Individual | ADP of the SNF | NOT APPLICABLE | 12/02/2023 |
| Fernandez, Edward | Individual | Corporate Director | NOT APPLICABLE | 09/08/2023 |
| Fernandez, Edward | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2025 |
| Hoerneman, Brian | Individual | Corporate Director | NOT APPLICABLE | 09/01/2023 |
| Hoerneman, Brian | Individual | Corporate Officer | NOT APPLICABLE | 04/04/2023 |
| Klebe, Samantha | Individual | Corporate Director | NOT APPLICABLE | 09/08/2023 |
| Klebe, Samantha | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2025 |
| Klebe, Samantha | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Marshfield Clinic Health System INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2019 |
| Mathison, Douglas | Individual | Corporate Director | NOT APPLICABLE | 12/15/2020 |
| MCHS Hospitals INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2019 |
| MCHS Hospitals INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2019 |
| McKuen, Laurie | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/23/2024 |
| McKuen, Laurie | Individual | ADP of the SNF | NOT APPLICABLE | 08/23/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Who on your staff manages IV therapy, and what training and monitoring is in place?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Beaver Dam Health Care Center | 0.2 mi | Beaver Dam, WI | ★☆☆☆☆ | 1/5 | abuseSFF |
| Clearview | 8.1 mi | Juneau, WI | ★★★★★ | 4/5 | |
| Clearview Brain Injury Center | 8.1 mi | Juneau, WI | ★★★★★ | 5/5 | |
| Randolph Health Services | 10.8 mi | Randolph, WI | ★★★☆☆ | 3/5 | |
| Columbus Health and Rehab | 12.9 mi | Columbus, WI | ★★☆☆☆ | 2/5 | |
| Complete Care at Christian Home LLC | 13.0 mi | Waupun, WI | ★★☆☆☆ | 2/5 | |
| Avina of Mayville | 14.0 mi | Mayville, WI | ★★★☆☆ | 3/5 | |
| Marquardt Memorial Manor | 18.0 mi | Watertown, WI | ★★☆☆☆ | 2/5 | |
| Watertown Health Care Center | 18.4 mi | Watertown, WI | ★☆☆☆☆ | 1/5 | SFF |
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Facility data as of CMS processing date 2026-08-01. CCN 525447.