Ingleside Manor: Medication Delays Leave Resident in Pain - WI
The resident, identified in inspection records only as R3, told federal inspectors on March 12, 2025 that she occasionally experienced chest pain and had to ask for nitroglycerin on the days her blood pressure medications didn't arrive on time, meaning by 9:00 AM. She said she remembered specific problems going back to December 18 and 19 of 2024, when her 8:00 AM medications didn't reach her until around 12:30 in the afternoon. The same thing happened again in March.
The medication administration records confirmed what she described.
On March 10, 2025, all of R3's scheduled 8:00 AM medications were signed off at 10:38 AM, flagged in the system as "late administration: administered late." Her medications that morning included carvedilol, a blood pressure drug she takes twice daily, along with liothyronine for her thyroid, torsemide, and fexofenadine. A dose of the antibiotic cephalexin, scheduled for noon that same day, wasn't given until 1:07 PM.
March 11 was worse. All of her 8:00 AM medications were charted as administered between 12:37 PM and 12:38 PM, more than four and a half hours late.
The December records showed their own pattern. On December 19, 2024, R3's evening dose was signed off as a late administration. Her 8:00 AM doses of folic acid, losartan, and torsemide on that same date were documented as given at 9:15 AM. The following day, December 20, her liothyronine and torsemide were recorded as not administered at all, with the notation "drug/item unavailable."
When inspectors interviewed the Director of Nursing on March 14, 2025, she was covering the floor herself. She told inspectors the facility's expectation was that medications be given within one hour before or one hour after the scheduled time. She confirmed the late administrations.
That window would put the outer limit for R3's 8:00 AM medications at 9:00 AM. The records showed medications arriving at 10:38 AM on one day and after 12:30 PM on multiple others, including dates going back three months.
Carvedilol, one of the medications R3. receives twice daily, is used to manage blood pressure and heart failure. Torsemide is a diuretic also used for those conditions. Liothyronine is a thyroid hormone replacement. Missing or significantly delaying any of these medications can affect how the drugs work across the day, particularly for a resident who reported physical symptoms when doses ran late.
R3 told inspectors she received her 8:00 AM medications well after 9:00 AM on both March 10 and March 11. She was clear about what that meant for her. She had chest pain. She had to ask for nitroglycerin.
The inspection, completed March 14, 2025, cited Ingleside Manor for failing to ensure medications were administered as ordered. Inspectors classified the harm level as minimal harm or potential for actual harm, with few residents affected.
The Director of Nursing confirmed the violations and was working the floor the day inspectors asked her about them.
R3 said she had been raising concerns about her medications since December.
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.
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Last verified: November 5, 2026 · Our methodology
Ingleside Manor in Mount Horeb, WI was cited for violations during a health inspection on March 14, 2025.
The same thing happened again in March.
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.