Ingleside Manor: Missed Transplant Meds, Multiple Days - WI
The missed drug was mycophenolate sodium, a 360-milligram immunosuppressant given twice daily to prevent the body from rejecting a transplanted organ. The first missed dose was the evening of August 20. The record shows a blank space where a nurse would have initialed to confirm administration. Two days later, on August 22, the morning dose wasn't given either, and this time someone wrote a reason: "Not Administered: Drug/Item Unavailable." The same notation appeared again on September 5.
Mycophenolate isn't optional. It suppresses the immune system's attack on transplanted tissue. Missing doses raises the risk that the body begins to reject the organ.
But mycophenolate wasn't the only medication this resident missed. Inspectors found that from August 20 through August 23, the resident also went without lacosamide, a seizure medication; levetiracetam, another seizure drug; and insulin aspart, a fast-acting insulin used to control blood sugar.
Four medications. Three days. A transplant patient.
When a state surveyor sat down with the facility's director of nursing on September 15, the questions were direct and the answers were unambiguous. The surveyor asked whether the director would have expected those medications to be administered as ordered. Yes, the director said. The surveyor asked whether she considered the missed doses to be medication errors. Yes again. The surveyor then asked whether staff, if the medications were available in contingency supply, should have pulled them from that supply and given them to the resident. Yes, the director said, she would have expected exactly that.
The facility's own contingency supply list, reviewed during the inspection, shows levetiracetam 250 mg with a quantity on hand of ten tablets. The backup supply existed. Nobody used it.
The director of nursing also told the surveyor that the pharmacy makes two deliveries per day. The explanation of "Drug/Item Unavailable" sits alongside that fact without resolving it. If the pharmacy delivers twice daily, the window during which a medication would be genuinely unreachable is narrow. The inspection report does not document that anyone called the pharmacy, contacted a physician, or sought an emergency supply during the days the resident went without her drugs.
The inspection was a complaint survey, meaning someone reported a concern before inspectors arrived. The visit occurred September 15, nearly four weeks after the stretch of missed medications in late August. By then, the documentation was already in the record, the contingency list was on file, and the director of nursing was able to confirm, question by question, that what happened was not supposed to happen.
CMS rated the violation at the level of minimal harm or potential for actual harm, the lower end of the deficiency scale. That rating reflects what inspectors could document, not necessarily what the resident experienced during the days she went without an immunosuppressant and insulin.
The resident is identified in the inspection report only as R3. What the report captures is a paper trail: a blank space on August 20, a typed notation on August 22, another on September 5, and a director of nursing who agreed, three times, that none of it should have occurred.
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 missed drug was mycophenolate sodium, a 360-milligram immunosuppressant given twice daily to prevent the body from rejecting a transplanted organ.
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.