Ingleside Manor: Incomplete Abuse Investigation - Mount Horeb, WI
The incident happened on December 19, 2024. According to CNA4, the two residents, identified in inspection records as R1 and R2, had a verbal argument and were separated. Later that evening, R1 told CNA4 that R2 had bopped her in the mouth. CNA4 said R1 didn't appear injured. CNA4 reported it immediately to the nurse on duty, RN6, and then heard nothing more about it.
Nobody from the facility ever called her back.
R1's family member, identified as FM1, spoke with R1 every night by phone. On the night of December 19, R1 told her that a woman had tried to get past her to use the phone and had backhanded her. FM1 tried to call the facility. No one answered. She sent an email instead.
The facility did open an investigation. The Assistant Administrator interviewed two residents and two aides, CNA3 and CNA5, on December 20. CNA3 said he hadn't seen the incident himself but had heard CNA5 talking about it, and had heard that CNA4 was the one who actually saw something. CNA5 said R2 had swung at her and CNA4 the evening before, but CNA5 did not witness R2 swing at R1.
The Assistant Administrator's email to the former Administrator that same evening noted CNA4's phone number and suggested someone reach out to her.
No one did.
CNA4 is an agency staff member, which may explain why she fell through the cracks. It does not explain why the crack was never noticed for three months. When inspectors interviewed CNA4 on March 12, 2025, she said she had not witnessed R2 hit R1 directly, but confirmed R1 had reported it to her and that she had passed it on to the nurse right away. She also described R2 as having a history of wandering and becoming combative with staff who tried to redirect her. CNA3 echoed that description, telling inspectors R2 could go from really happy to really upset quickly for no known reason.
By the time inspectors arrived in March, both residents were doing fine. R2 smiled during her interview and said everyone at the facility was nice, that she had never hit anyone, and that no one had ever hit her. R1 remembered R2 ramming into the back of her wheelchair and recalled telling a nurse about it. She couldn't remember whether R2 had actually touched her, but said she felt the nurse had handled it, because R2 hadn't bothered her since.
The Assistant Administrator, interviewed on the final day of the inspection, offered a candid accounting of what went wrong. She explained that at the time of the incident, she had been primarily responsible for the non-nursing portion of the building, while the former Administrator oversaw the nursing facility side. She said she had not been deeply involved in the investigation beyond her two resident interviews and two staff interviews. She could not confirm whether any additional staff interviews had been conducted.
Then she said it plainly: the investigation was not thorough.
She added that, had she been running it, she would have contacted everyone who had been on the schedule that shift, and on previous shifts, to understand what might have escalated R2's behavior.
That did not happen. The aide who reported the allegation to the nurse in real time, on the night it occurred, waited three months before anyone thought to ask her what she saw.
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.
The incident happened on December 19, 2024.
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.