Hillside Manor

In the surveyor’s words

From the most serious findings on record at Hillside Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 21, 2025

  Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 out of 4 sampled residents (R1) by failing to serve R1 the correct diet and failing to administer first aid (Heimlich Maneuver) timely when R1 experienced a choking episode. R1 experienced a choking episode that required the Heimlich maneuver to clear R1's airway. The facility did not complete all assessments of Vital Signs (VS) and respirations over the next 24 hours. At supper the following day, the facility did not ensure that R1 received the proper downgraded diet of bite sized and soft food items. R1's meal card indicated R1 could be served a dinner roll, which was served. […]

• Actual harm, isolatedF686Mar 12, 2026

  Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 (R9) of 2 residents reviewed for PIs out of a sample of 15 residents.R9 had a care plan intervention to use a Roho cushion in R9's wheelchair and recliner. The facility staff failed to ensure the Roho was properly inflated and functioned according to manufacturer's recommendations and failed to ensure weekly skin assessments were completed once R9 developed a full thickness. Findings include:The National Pressure Injury Advisory Panel (NPIAP) classifies a PI as follows: Stage 3: Full thickness tissue loss. […]

• Actual harm, isolatedF689Nov 14, 2024

  Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 3 of 4 residents reviewed (R37, R12, and R36) for accidents. R37 and R12 are being cited at severity level 3 (actual harm) R36 is being cited at severity level 2 (potential for more than minimal harm). R37 has a history of multiple falls, primarily from her lift chair. Facility staff did not implement fall interventions. R37 had one fall that resulted in a fracture of her right elbow and a laceration to forehead requiring staples, and another fall that resulted in fracture of her clavicle and a laceration to her head requiring staples. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based on observation, interview, and record review the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 58 residents. Surveyor observed dried food drips on the outside of the oven doors. Surveyor observed personal, unmarked food in the beverage cooler. Surveyor observed a half loaf of bread undated and with visible freezer burn in the freezer. Surveyor observed burger patties improperly sealed in the freezer. Surveyor observed dessert bars not dated or marked and not properly closed in the bakery freezer. Surveyor observed trash cans in the food prep area to not have lids. […]

• No harm, potential for more than minimal, widespreadF804Nov 14, 2024

  Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 52 residents. Residents (R) voiced concerns of food not being served at a desirable temperature (R32, R41, R46, and R28). 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy, titled Food and Nutrition - Trayline Taste and Temperature Log Procedure, dated 10/15/24, includes in part: . The purpose of Menu Works Daily Service Patient/Resident Taste and Temperature Log is to monitor taste and temperatures on the service line for Patient/Resident food service . Standard Temperatures . […]