Ingleside Manor: Pressure Injury Prevention Failures - WI
That is what a federal surveyor found on the morning of September 11, 2025, at Ingleside Manor, a nursing home on North Eighth Street in Mount Horeb, Wisconsin. The surveyor arrived in the room of a resident identified in inspection records as R6 at 8:30 in the morning and did not leave until 9:28. In that 58 minutes, no staff member came in to offer R6 a repositioning. No one moved the pressure-offloading cushion from the wheelchair to the recliner where she was sitting. The specialty mattress on her bed, which was supposed to be set to pulsate to relieve pressure on her skin, was set to static.
R6 has Multiple Sclerosis, a history of cerebral infarction, major depressive disorder, muscle weakness, and heart failure. She had been living at Ingleside Manor since August 2025. By the time the surveyor walked into her room, she had already been formally assessed as at risk for pressure injury and had already developed a stage 2 wound at her coccyx. Her physician had responded with specific, written orders: a pulsating specialty mattress, a pressure-offloading cushion whenever she was up in a chair, and repositioning every 30 minutes while she was out of bed.
None of those orders were in the document the aides were actually using to care for her.
The facility uses what it calls a Resident Profile sheet, a summary document that certified nursing assistants consult to guide daily care. R6's profile sheet, as of the day of the inspection, contained no mention of pressure injury prevention whatsoever. No cushion. No repositioning schedule. No mattress setting. The orders existed in the physician's chart. They existed in the care plan, which had been printed four days before the survey. They just had not made it to the sheet the people providing hands-on care were told to follow.
When the surveyor spoke with CNA D at 9:28 that morning, the aide confirmed that the profile sheet was where CNAs looked for information about what a resident needed. When the surveyor spoke with CNA H that afternoon, the same answer came back: pressure injury interventions would be on the Resident Profile sheet. CNA H said it plainly. That is where you would find it.
It was not there.
The Director of Nursing, identified in the report as DON B, confirmed the gap when the surveyor brought the findings to her later that day. DON B said R6 should have a pulsating mattress. DON B said R6 should have a cushion when she is up in her chair. DON B said staff should be making sure those things are in place. When the surveyor described what she had actually observed, the static mattress setting and the cushion sitting idle in the wheelchair while R6 sat in the recliner, DON B acknowledged that R6's interventions were not being followed and said they should be.
She did not dispute any of it.
A stage 2 pressure injury means the skin has already broken down. The outer layer and part of the layer beneath it are gone. What remains is an open wound, or a blister, or exposed tissue at a site where bone presses against skin. For a resident sitting in a recliner without a pressure-offloading cushion, the coccyx, the very site of R6's wound, bears weight directly. The physician's order for repositioning every 30 minutes exists because prolonged pressure on a wound site impedes blood flow and prevents healing. Fifty-eight minutes passed in that room with no repositioning and no cushion.
The facility's own policies, one dated April 2020 and one from April 2018, describe what is supposed to happen. Nursing staff are to assess and document risk factors. Physicians are to order pressure reduction surfaces. Support surfaces are to be selected based on the resident's risk factors. Current treatments, including support surfaces, are to be documented. The care plan printed on September 11 listed the pressure injury as an active problem with a start date of August 11, 2025, and included approaches directing staff to consider a specialty mattress, to elevate heels and use protectors, and to use a specialty chair pad when positioning R6 in a chair or wheelchair.
The orders were there. The care plan was there. The problem had been identified a full month before the surveyor walked in.
What was not there was any mechanism ensuring that the aides who moved R6 from her bed to her recliner each morning knew what her doctor had ordered for her wound. The profile sheet, the document CNAs were trained to consult, was silent on the subject. Two different aides, interviewed hours apart, both pointed to that same sheet as the place where they would expect to find pressure injury guidance. Neither of them had it.
This was a complaint inspection, meaning someone contacted regulators before the surveyor arrived. The inspection covered one resident, R6, and found one deficiency, but it was not a close call. The surveyor did not have to search for the problem. She walked into the room, sat down, and watched it happen in real time for nearly an hour. The cushion was visible. The mattress control was visible. The absence of any staff contact during that window was observable and documented.
CMS rated the harm level as minimal harm or potential for actual harm, the lower end of the scale. But a stage 2 wound is not a hypothetical. R6 already had the injury. The question the inspection raised was not whether she might develop a pressure wound someday. It was whether the facility was doing what her physician ordered to keep the wound from getting worse.
On the morning of September 11, while a surveyor sat in her room and watched, the answer was no.
R6 told the surveyor she had a pressure injury on her buttocks. She was sitting in her recliner. The cushion that was supposed to be under her was three feet away in her wheelchair. The mattress that was supposed to be moving beneath her was still.
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.
The surveyor arrived in the room of a resident identified in inspection records as R6 at 8:30 in the morning and did not leave until 9:28.
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.