Cycle 1
Health 2024-11-14 · Fire 2024-11-14
17 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Beaver Dam, WI
Hillside Manor
3-star overall rating with 2-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
803 S University Ave, Beaver Dam, WI
(920) 887-5901
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
115
Certified beds
Average residents
51
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Sanford Health Good Samaritan (Prospera)
Operator or chain grouping
Approved since
1989-11-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 2 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.87
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.10
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,520
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0111
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.39
Baseline 17.76% · Performance 18.00% · Measure score 7.39 · Achievement 7.39 · Improvement 0
Healthcare-associated infections
7.75
Baseline 6.54% · Performance 5.52% · Measure score 7.75 · Achievement 7.75 · Improvement 6.11
Total nurse turnover
5.57
Baseline 35.00% · Performance 40.91% · Measure score 5.57 · Achievement 5.57 · Improvement 0
Adjusted total nurse staffing
1.69
Baseline 4.44 hours · Performance 3.56 hours · Measure score 1.69 · Achievement 1.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.8% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 2.5% · Lower 95% interval 6.02% |
| Discharge to community | 50.43% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 48.75% · Lower 95% interval 39.95% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.25% |
95.27%
3 pts better
|
Numerator 56 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 54.9% |
53.69%
1.2 pts better
|
Numerator 28 · Denominator 51 |
| Discharge mobility score | 58.82% |
50.94%
7.9 pts better
|
Numerator 30 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 57 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.52% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 0% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 11.11% |
8.2%
2.9 pts better
|
Numerator 9 · Denominator 81 |
| Staff flu vaccination coverage | 92.68% |
42%
50.7 pts better
|
Numerator 76 · Denominator 82 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 34 · Denominator 51 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.41% |
25.2%
17.8 pts worse
|
Numerator 2 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.2%
0.5 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · Q3 5.0% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
5.0%
4.3 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
4.9%
3.7 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 11.8% · Q3 6.1% · Q4 8.3% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
16.6%
7 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 8.3% · Q3 8.8% · Q4 5.3% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
16.7%
11.5 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 8.0% · Q3 0.0% · Q4 2.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.5% |
21.1%
5.6 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
17.3%
6.3 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.1% · Q3 6.9% · Q4 8.8% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
3.0%
0.2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 2.6% · Q4 5.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
25.5%
7.2 pts better
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 12.5% · Q3 23.1% · Q4 14.1% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.5%
4.4 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
86.8%
9.8 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 94.9% · Q4 93.1% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
15.0%
3.7 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 16.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.2% |
82.2%
1 pts worse
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
22.7%
8.5 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 11.1% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-06-28 · Fire 2022-06-28
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-11-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-11-19
E · Potential for more than minimal harm
2023-09-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-09-07
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-09-07
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-09-22
C · Minimal harm
2023-09-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-27
F · Potential for more than minimal harm
2022-06-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-19
F · Potential for more than minimal harm
2022-06-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-06-23
E · Potential for more than minimal harm
2022-06-28
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-06-23
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-07-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-07-21
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-24
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-24
G · Actual harm
2024-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-11-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-11-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-11-14
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-14
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-12-31
E · Potential for more than minimal harm
2023-09-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-07
F · Potential for more than minimal harm
2022-06-28
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-07-20
Penalties and ownership
What sits behind the stars
$0
2024-11-14
Payment Denial
Payment Denial · denial start 2024-12-11 · 20 days
20 day denial
Ownership
Mchs Hospitals Inc
5% Or Greater Direct Ownership Interest · Organization
Baltus, John
Corporate Director · Individual
Baltus, John
Corporate Officer · Individual
Buswell Cleary, Lindsey
Operational/Managerial Control · Individual
Fernandez, Edward
Corporate Director · Individual
Fernandez, Edward
Corporate Officer · Individual
Hoerneman, Brian
Corporate Director · Individual
Hoerneman, Brian
Corporate Officer · Individual
Klebe, Samantha
Corporate Director · Individual
Klebe, Samantha
Corporate Officer · Individual
Marshfield Clinic Health System Inc
5% Or Greater Indirect Ownership Interest · Organization
Mathison, Douglas
Corporate Director · Individual
Mchs Hospitals Inc
Operational/Managerial Control · Organization
Mckuen, Laurie
Operational/Managerial Control · Individual
Morrison, Tony
Operational/Managerial Control · Individual
Munson, Jolyn
Operational/Managerial Control · Individual
Newcomb, Everett
Corporate Director · Individual
Olson, Nicholas
Operational/Managerial Control · Individual
Poppen, Jeffrey
Operational/Managerial Control · Individual
Poppen, Jeffrey
Corporate Officer · Individual
Procci, Linda
Corporate Director · Individual
Sanford
5% Or Greater Indirect Ownership Interest · Organization
Smith, Dennis
Corporate Director · Individual
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
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