Ingleside Manor: Abuse Report Delayed After Resident Hit - WI
Management says they didn't find out until someone read an email.
Federal inspectors documented the disconnect during a March 2025 survey at the 407 N. Eighth Street facility, a nursing home in the small Dane County community of Mount Horeb. What they found was not a case of staff failing to report, but of a reporting system so fractured that an allegation of resident-on-resident abuse traveled from two aides to a registered nurse and then, apparently, nowhere — while the facility's leadership remained in the dark for days, and a family member's after-hours email sat waiting to be read.
The resident at the center of the allegation, identified in inspection records as R1, told a family member what had happened on the night it occurred. That family member, identified as FM1, spoke with R1 every evening by phone. On December 19, R1 told her that a woman had tried to get past her to use the phone and had backhanded her. R1 said she had already told the staff.
FM1 tried to call the facility. No one answered. She sent an email instead.
R1 told inspectors, during an interview on March 11, that R2 had rammed into the back of her wheelchair with her own wheelchair. R1 couldn't recall whether R2 had made direct physical contact with her, but she remembered telling a nurse what had happened. She said she felt the nurse had addressed it, because R2 hadn't bothered her since.
R2, interviewed the same morning, smiled and said everyone at the facility was nice. She said she had never hit anyone, and no one had ever hit her.
CNA4, who worked the evening shift from 2:00 to 10:00 PM on December 19, told inspectors she had not witnessed R2 strike R1. But R1 had reported it to her directly that night, and CNA4 said she reported it immediately to the nurse on duty, Registered Nurse 6. CNA3, also working that evening shift, gave inspectors the same account. He didn't see it happen, but R1 told him R2 had hit her in the face. He went right to the nurse.
RN6, the nurse both aides reported to, was not available for interview during the survey.
That absence matters. Because what happened after two aides walked to the nurse's station and reported an allegation of abuse is, based on the inspection record, unknown. The allegation does not appear to have moved further up the chain that night. The facility's own stated standard was a two-hour window for reporting abuse allegations.
The Assistant Administrator, interviewed on the morning of March 14, described a management structure that helps explain how something can be reported and still go nowhere. At the time of the incident, she said, she was primarily overseeing the non-nursing portion of the building. The former Administrator oversaw the nursing facility side. She said she was not really involved in the reporting of the allegation.
As far as she knew, she told inspectors, the facility did not become aware of the allegation until the former Admissions Director read FM1's email.
She acknowledged the two-hour reporting window. Then she offered an explanation that the inspection record does not treat as a defense: families often emailed, she said, which put the facility past that two-hour timeframe.
She was unaware, at the time of her interview, that CNA4 and CNA3 had both reported the allegation to RN6 on the night it happened.
That detail is the core of what inspectors documented. The failure here was not that staff stayed silent. Two aides reported what a resident told them, on the same shift, to the same nurse. The failure was what came next, or rather, what didn't. An allegation of a resident being struck in the face moved from the floor to a nurse and then stopped. The facility's leadership learned of it not through its own internal chain of communication, but through an email a family member sent when she couldn't reach anyone by phone.
The deficiency was cited under federal abuse reporting standards and cross-referenced to F610, which addresses the investigation and reporting of alleged violations. The level of harm was assessed as minimal harm or potential for actual harm. Few residents were identified as affected.
Those classifications are regulatory language. What they describe, in practice, is an 80-something woman telling two different staff members on the same evening that another resident hit her in the face, and the facility's management not knowing about it until they read their inbox.
R1 told inspectors she felt the nurse had handled it. She based that on the fact that R2 hadn't bothered her since. That may be true. It may also be that a resident, having reported what happened to two aides and a nurse, simply decided that was enough, and moved on, and tried not to think about it.
FM1, who called every night and couldn't get through, sent an email and waited.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ingleside Manor from 2025-03-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 5, 2026 · Our methodology
Ingleside Manor in Mount Horeb, WI was cited for abuse-related violations during a health inspection on March 14, 2025.
Management says they didn't find out until someone read an email.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.