Ingleside Manor: Suicide Risk Resident Had No Care Plan - WI
That was the finding when inspectors arrived at the 407 N. Eighth Street nursing home on September 15, 2025, responding to a complaint. The resident, identified in inspection records only as R1, had a documented history of suicide attempts and suicidal ideation. No active care plan addressed it. No safety interventions were in place.
The facility's own licensed practical nurse confirmed it.
When a surveyor asked whether a care plan should have been developed given R1's history, LPN I, as the nurse is identified in the report, said yes, it should have been. The history of suicide attempts should have been care planned. But it wasn't in the active phase. Safety interventions, the nurse acknowledged, should have been in place for R1.
That acknowledgment came not from an outside expert or a family member pushing for answers. It came from inside the building, from a staff member who told inspectors he tries to help alongside the Director of Nursing and the facility's MDS Nurse.
Trying to help is not the same as having a plan.
A care plan in a nursing home setting is the document that drives everything, what staff watch for, what they do when warning signs appear, how they communicate across shifts. For a resident with a history of multiple suicide attempts, that document would typically spell out what precautions are in place, how often the resident is monitored, and what interventions follow any sign of distress. Without it, staff on any given shift have no formal guidance. There is no record of what was agreed upon. There is no accountability for whether anyone checked.
Inspectors classified the deficiency as causing minimal harm or potential for actual harm, affecting few residents. The language is regulatory shorthand. What it describes, in this case, is a person with a known history of trying to end their life living in a facility that had not written down how to keep them safe.
The inspection report does not say how long R1 had been a resident. It does not say how recently the suicide attempts occurred, or whether staff were aware of them through verbal report or formal documentation. It does not say whether anything happened to R1 before inspectors arrived. The report captures a moment: a surveyor asking a direct question, a nurse giving a direct answer, and a care plan that did not exist.
What the report does make clear is that the gap was not a secret. The LPN knew. He said so. The Director of Nursing was named as someone involved in care planning. The MDS Nurse, whose job centers on assessing and documenting resident needs, was also identified. The oversight was not buried in a chart no one had read. The people responsible for care planning at Ingleside Manor were aware of R1's history, and the active safety documentation still was not there.
Ingleside Manor is a nursing facility in Mount Horeb, a small city roughly 25 miles west of Madison. The September 2025 inspection was a complaint survey, meaning someone, a resident, a family member, a staff member, contacted authorities before inspectors walked through the door.
The inspection report does not describe what prompted the complaint. It does not name R1 or provide details about their condition beyond the history of suicide attempts and suicidal ideation. It does not say whether R1 is still a resident at the facility.
For a plan of correction, the report directs readers to contact the nursing home or the state survey agency directly.
The LPN's words, recorded by a federal surveyor and entered into the official record, are what remain. R1 should have been care planned. Safety interventions should have been in place.
They were not.
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 was the finding when inspectors arrived at the 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.