Ingleside Manor: Medication Timing Failures - WI
The inspection, triggered by a complaint and conducted on September 11, 2025, found that a resident identified in records as R6 had not received her 8:00 AM medications as of 10:46 AM that morning. That is a gap of two hours and forty-six minutes, well outside the window that both the facility's nursing staff and its director described as acceptable.
The standard, as LPN F explained to the surveyor that afternoon, is a two-hour window. A medication scheduled for 8:00 AM can be given as early as 7:00 AM or as late as 9:00 AM. Anything outside that range is a medication error. No ambiguity. No gray area.
Director of Nursing B said the same thing. When the surveyor raised R6's case specifically, DON B confirmed that because the medications had not been given by 10:46 AM, they were late. "Medications should be administered timely," DON B told the surveyor, "and R6's was not."
The inspection classified the harm level as minimal, or potential for actual harm, and noted that the problem affected some residents, not just one.
What the inspection report does not say is what R6's medications were for. It does not say whether she asked for them, whether anyone noticed they were late, or whether anything was done once the gap was discovered. The record contains the error and the admission. It does not contain the explanation.
That absence is its own kind of detail. A medication error serious enough to prompt a complaint inspection, confirmed by the facility's top nursing official, and the public record ends at the acknowledgment.
Ingleside Manor sits on North Eighth Street in Mount Horeb, a small community of roughly seven thousand people in Dane County, southwest of Madison. For residents who depend on the facility for daily care, the gap between a scheduled dose and an actual dose is not an abstraction. It is the difference between pain managed and pain left to build, between a condition stable and a condition that is not.
The two-hour window exists precisely because timing matters for many medications. Blood pressure drugs, diabetes medications, seizure treatments, and pain management regimens are all built around consistent schedules. A nearly three-hour delay does not fall just outside the window. It nearly doubles it.
DON B did not dispute any of this. Neither did LPN F. The facility's own staff provided the clearest account of what went wrong, and both arrived at the same word for it.
The inspection was completed September 15, 2025. The plan of correction, if one was submitted, is available through the facility or the state survey agency. What is already on the record is the error, the resident who experienced it, and the director who confirmed it out loud.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ingleside Manor from 2025-09-15 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
INGLESIDE MANOR in MOUNT HOREB, WI was cited for violations during a health inspection on September 15, 2025.
That is a gap of two hours and forty-six minutes, well outside the window that both the facility's nursing staff and its director described as acceptable.
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.