Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

HILLSIDE MANOR

BEAVER DAM, WI · 115 certified beds · Last Life Safety survey March 12, 2026

CMS Certification Number 525447 · first certified November 1989

Ownership

Operated by SANFORD HEALTH · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

8
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
3
Inspection & testing records
Of the citations on file

Position within WI

8 citations — more than 11% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 0 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens April 2027 — about 7 months from now. This facility’s last Life Safety survey was March 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 8 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 8 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.

This facility8WI median17National median11
Citations on file over three years, compared
MeasureCitations
This facility8
Median facility in WI17
Median facility nationally11

Survey history

Citations at each Life Safety survey
42023-0942024-1102026-03
Citations at each Life Safety survey
Survey dateCitations
September 7, 20234
November 14, 20244
March 12, 20260

Most-cited tags

Most-cited tags at this facility
K-07122K-05111K-07811K-02251K-07531E-00041K-01311
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0712Have simulated fire drills held at unexpected times.22024-11-14
K-0511Have properly installed electrical wiring and gas equipment.12024-11-14
K-0781Have restrictions on the use of portable space heaters.12023-09-07
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.12023-09-07
K-0753Have restrictions on the use of highly flammable decorations.12024-11-14
E-0004Develop and maintain an Emergency Preparedness Program (EP).12024-11-14
K-0131Meet requirements for sections of health care facilities separated by fire resistive construction.12023-09-07

What the citations cover

Citations by CMS category
  • Miscellaneous Deficiencies 4
  • Construction Deficiencies 1
  • Emergency Preparedness Deficiencies 1
  • Services Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Miscellaneous Deficiencies4
Construction Deficiencies1
Emergency Preparedness Deficiencies1
Services Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 14, 2024 — 4 citations

Citations issued on November 14, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (December 31, 2024)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (December 31, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 31, 2024)
K-0753Have restrictions on the use of highly flammable decorations.Deficient, Provider has date of correction (November 19, 2024)

September 7, 2023 — 4 citations

Citations issued on September 7, 2023
TagWhat the surveyor checksStatus
K-0131Meet requirements for sections of health care facilities separated by fire resistive construction.Deficient, Provider has date of correction (September 8, 2023)
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (October 2, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (September 27, 2023)
K-0781Have restrictions on the use of portable space heaters.Deficient, Provider has date of correction (September 22, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.