Ingleside Manor: Resident Went Days Without Eating - WI
That account came from the aide himself, during an inspection at Ingleside Manor on March 14, 2025.
The aide, identified in inspection records as CNA 3, described the resident, R4, as someone who ate well under normal circumstances, especially when a particular family member helped feed her. She had been stable for a long time. Then, abruptly, she stopped eating. Other aides passed the information along in shift reports. CNA 3 said he received that information and observed it himself.
He could not recall if he reported it to a nurse.
CNA 3 told inspectors he would normally notify a nurse when a resident stopped eating. This time, he said, he just wasn't sure if he had. He offered one possible explanation for the gap: the facility had been running with a lot of agency nurses.
The Director of Nursing, interviewed the same day, said the expectation was clear. If a resident was not eating or drinking, hospice and the family were supposed to be notified within a day. That was the standard.
Then the DON raised a different question entirely. She asked whether R4 had really gone two or three days without eating, or whether staff had simply passed along inaccurate information through the reporting chain.
It was a reasonable question. It was also, in some ways, the more troubling one. If the information passed between aides was unreliable, that was one problem. If it was accurate and never reached a nurse, that was another. The inspection record does not resolve which it was.
What the record does establish is this: a nonverbal resident who depended entirely on staff to notice and report changes in her condition experienced a significant change, aides knew about it, and the communication system that was supposed to move that information to a nurse either failed or was never used. She ended up in the emergency room.
CMS rated the violation at the minimal harm level, meaning inspectors concluded the lapse did not result in serious injury. But the category describes outcome, not process. The process here was a resident who could not advocate for herself, in a building where the aide who saw the problem could not say, weeks later, whether he had told anyone with the authority to act.
Agency staffing in nursing homes has become a persistent variable in care breakdowns. Temporary nurses, unfamiliar with residents and their baselines, depend more heavily on aides to flag changes. When aides are uncertain who is on duty, or assume someone else has already reported, or simply cannot recall, the gap between observation and action widens. CNA 3 did not say he decided not to report. He said he could not remember.
The DON's response to inspectors did not indicate that any investigation into the communication failure had been completed, or that the facility had identified where in the chain the information stopped moving. Her comment questioning whether R4 had actually gone without eating for that long suggested the facility's own account of what happened remained unsettled at the time of the inspection.
R4 was already at the hospital by then.
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 violations during a health inspection on March 14, 2025.
That account came from the aide himself, during an inspection at Ingleside Manor on March 14, 2025.
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.