Ingleside Manor: Wound Infection After Missed Alerts - WI
That is what federal inspectors found when they investigated Ingleside Manor, a nursing facility at 407 N. Eighth Street in Mount Horeb. The resident, identified in inspection records only as R2, had been admitted with a wound on her left abdomen. While in the facility's care, the wound increased in size and developed what staff themselves later described as a foul odor. No physician was notified in time. R2 was sent back to the hospital with a diagnosis of a wound infection.
The inspection, completed September 15, 2025, rated the violation as causing actual harm.
Inspectors found the facility had failed to complete ongoing comprehensive wound assessments during R2's stay. Notes lacked basic wound characteristics: the type of wound, the condition of the wound bed, the appearance of surrounding tissue, whether there was drainage, whether there was odor. The documentation that did exist told a damaging story on its own.
Between August 20 and August 22, the wound got bigger. A note entered on August 24 recorded that a wound assessment performed on August 22 had found a foul odor. No physician was contacted about either development.
The Director of Nursing, identified in the report as DON B, told inspectors she first personally assessed R2's wounds on August 22, and that was the first time she noticed the odor herself. She said it was included in her note. When the inspector pointed out that the August 24 note documented foul odor from the August 22 visit, and asked whether a physician should have been notified at that time, DON B said yes. When asked whether a physician should have been notified when the wound increased in size between August 20 and August 22, she said yes to that too.
Nobody had.
The inspector also pressed DON B on whether LPNs are permitted to perform assessments. She said no. She said an RN should review all LPN assessments. That matters because wound monitoring at the facility appears to have passed through LPN hands without the required RN oversight, and without the kind of complete documentation that would have captured what was happening to R2's wound in time to act on it.
The nurses interviewed that morning were consistent on what should trigger a call to a physician. RN L, interviewed at 9:00 AM, listed changes in drainage, changes in wound appearance, redness, swelling, warmth, increased pain, and odor. LPN I, interviewed twenty minutes later, said any signs of deterioration, stalling, drainage changes, tissue changes, or worsening should go to a physician, and specified that odor would be a sign of deterioration. DON B, interviewed at 10:36 AM, named the same indicators: increased redness, drainage, odor, pain.
Everyone knew the rules. The call still wasn't made.
What the inspection record does not contain is any explanation for the gap. No note documenting a physician conversation that inspectors simply couldn't locate. No entry suggesting someone weighed the odor and decided it wasn't significant. The documentation of R2's wound characteristics was incomplete throughout her stay, which means the facility didn't have a clear record of what was happening to the wound from one day to the next, and the physician was never given the chance to intervene.
By the time R2 left Ingleside Manor, she had a wound infection serious enough to require hospitalization.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
INGLESIDE MANOR in MOUNT HOREB, WI was cited for violations during a health inspection on September 15, 2025.
That is what federal inspectors found when they investigated Ingleside Manor, a nursing facility at 407 N.
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.