Ingleside Manor: Catheter Bag Left on Floor - WI
The resident, identified in inspection records only as R6, told a state surveyor on the morning of September 11, 2025, that she had a history of urinary tract infections and was worried about the care she was receiving for her catheter tubing and drainage bag. The bag, at that moment, was on the floor next to her chair.
She was right to be worried. Bacteria travel up catheter tubing. Bags that rest on the floor pick up contaminants from one of the dirtiest surfaces in any care environment. R6 has a suprapubic catheter, a tube inserted directly through her lower abdomen into her bladder, which means any infection that develops has a direct path to a surgically created opening in her body.
The facility's own written instructions, in at least three separate documents, said exactly what should not happen. R6's care plan said it plainly: "Do not allow tubing or any part of the drainage system to touch the floor." Her CNA profile sheet said the same thing. The facility's catheter care policy, in place since 2014, listed keeping tubing and drainage bags off the floor as a basic infection control measure. The words were consistent across every document. The bag was on the floor anyway.
When the surveyor spoke with a certified nursing assistant, identified as CNA D, about what she had observed, the aide acknowledged the bag should not be there. Then the aide moved it. The correction took seconds. The bag had apparently been sitting on the floor since at least the start of the morning shift.
Later that afternoon, the Director of Nursing, identified as DON B, told the surveyor that catheter bags should hang below the level of the resident's bladder and should not be placed on the floor. When the surveyor described what she had seen in R6's room that morning, the Director of Nursing said the bag should not have been there.
Nobody disputed what had happened. Nobody offered an explanation for how it had happened.
The inspection was a complaint survey, meaning someone had raised a concern before surveyors arrived. The deficiency was cited at the lowest level of harm, described as minimal harm or potential for actual harm. That classification reflects CMS's assessment of what was documented, not a guarantee that nothing went wrong. R6 had already told the surveyor she was concerned. She had a history of urinary tract infections. How many mornings she had spent in that recliner with the bag on the floor before September 11 is not recorded in the inspection report.
Ingleside Manor is a nursing facility at 407 North Eighth Street in Mount Horeb, a small city in Dane County. The facility serves residents who, by definition, cannot manage their own medical equipment without help. A suprapubic catheter is not a minor accommodation. It requires daily cleansing and careful attention to prevent infection in and around the surgical site. R6's physician orders, dated the same day as the inspection, specified daily cleansing with mild soap and water, patting dry with a soft towel. The drainage bag was supposed to be part of a managed system. It was on the floor.
The Director of Nursing and the nursing assistant both knew the correct procedure when asked. The care plan knew it. The policy knew it. R6 knew something was wrong and said so out loud to a stranger with a clipboard.
She had been sitting there, watching the bag on the floor, long enough to have formed a concern she felt she needed to raise.
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.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
INGLESIDE MANOR in MOUNT HOREB, WI was cited for violations during a health inspection on September 15, 2025.
The bag, at that moment, was on the floor next to her chair.
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.