Ingleside Manor
INGLESIDE MANOR in MOUNT HOREB, WI — inspection on March 14, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 03/14/25 at 2:15 PM, the Director of Nursing (DON) stated if a resident was not eating or drinking, hospice and family were to be notified within a day.
The DON questioned if R4 really did not eat for two or three days or if staff passed along information that was not accurate.
525331 03/14/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
During an interview on 03/11/25 at 12:25 PM, R1 reported R2 had rammed into the back of my wheelchair with her wheelchair. R1 could not recall if R2 touched her but did recall telling the nurse what had happened. R1 felt the nurse addressed it because she [R2] hasn't bothered me since.
During an interview on 03/11/25 at 2:57 PM, FM1 stated she spoke to R1 each night. On 12/19/24, R1 told FM1 that a woman tried to get past her to use the phone and had backhanded her. R1 told FM1 she had told the staff. FM1 tried to call the facility but no one answered, and so she sent an email.
During an interview on 03/12/25 at 4:10 PM, Certified Nurse Aide (CNA) 4 reported she had not witnessed R2 hit R1 when she worked the evening shift (2:00 PM to 10:00 PM) on 12/19/24. CNA4 recalled R1 reported to her on 12/19/24 that R2 had bopped her in the mouth, and CNA4 reported it immediately to the nurse (Registered Nurse (RN) 6).
During an interview on 03/13/25 at 2:51 PM, CNA3 stated he did not witness R2 hit R1, but R1 reported to him on the evening shift on 12/19/24 that R2 hit her in the face. CNA3 stated he went right to the nurse to report the allegation.
During an interview on 03/14/25 at 8:30 AM, the Assistant Administrator stated at the time of the allegation, she was primarily overseeing the non-nursing facility part of the building while the former Administrator oversaw the nursing facility, so she was not really involved in the reporting of the allegation.
The Assistant Administrator reported as far as she knew, the facility was not aware of the allegation until the former Admissions Director read the email.
The Assistant Administrator stated the timeframe for reporting an allegation of abuse was two hours.
The Assistant Administrator stated families often emailed, which put us after the two-hour timeframe.
The Assistant Administrator was unaware that staff had reported the allegation made by R1 to the nurse the night it occurred.
RN6 was not available for interview during the survey.
Cross-reference: F-F610
525331 03/14/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
During the interviews, CNA3 stated he had not witnessed the incident
at her and CNA4 the evening before. CNA5 did not witness R2 swing at R1.
The email stated, [CNA4] is an agency staff member.
Her phone number is . if you would like to reach out.
During an interview on 03/11/25 at 9:15 AM, R2 smiled and reported everyone at the facility was nice, and she had never hit anyone, nor had anyone ever hit her.
During an interview on 03/11/25 at 12:25 PM, R1 reported R2 had rammed into the back of my wheelchair with her wheelchair. R1 could not recall if R2 touched her but did recall telling the nurse what had happened. R1 felt the nurse addressed it because she [R2] hasn't bothered me since.
During an interview on 03/11/25 at 2:57 PM, FM1 stated she spoke to R1 each night. FM1 recalled on 12/19/24, R1 told FM1 that a woman tried to get past her to use the phone and had backhanded her.
R1 told FM1 she had told the staff. FM1 tried to call the facility but no one answered, and so she sent an email.
During an interview on 03/12/25 at 10:40 AM, the Assistant Administrator reported she had interviewed R1 and R2 as well as CNA3 and CNA5.
The Assistant Administrator stated the former Administrator interviewed the other staff and residents.
The Assistant Administrator was unable to verify if CNA4 had been contacted.
During an interview on 03/12/25 at 4:10 PM, CNA4 reported she had not witnessed R2 hit R1. CNA4 recalled that on 12/19/24 the two residents had a verbal altercation and had been separated. R1 later reported to CNA4 that R2 had bopped her in the mouth, and CNA4 reported it immediately to the nurse [RN6]. CNA4 recalled R1 did not seem injured. CNA4 stated R2 had a history of wandering and being combative with staff who tried to redirect her. CNA4 stated no one from the facility had reached out to her regarding the incident.
During an interview on 03/13/25 at 2:51 PM, CNA3 stated R2 went from really happy to really upset quickly for no known reason, but he did not believe R2 had ever hit another resident prior to 12/19/24.
CNA3 stated he did not witness R2 hit R1, but R1 reported to him that R2 hit her in the face. CNA3 stated he went right to the nurse to report the allegation.
During an interview on 03/14/25 at 8:30 AM, the Assistant Administrator stated at the time of the allegation, she was primarily overseeing the non-nursing facility part of the building while the former Administrator oversaw the nursing facility, so she was not really involved in the investigation outside of assisting with the two resident and two staff interviews.
She could not verify that any further staff interviews were conducted outside of the two she completed.
The Assistant Administrator confirmed the investigation was not thorough.
The Assistant Administrator stated she would have reached out to everyone on the schedule that shift as well as previous shifts, to find out more about what may have escalated any behaviors.
Cross-reference to F-F609
525331 03/14/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
Review of R3's Medications Administration History report provided by the facility for the dates of 03/10/25 to 03/12/25 revealed all 8:00 AM medications on 03/10/25 were signed off at 10:38 AM with the note late administration: administered late.
The noon dose of cephalexin on 03/10/25 was given at 1:07 PM.
All 8:00 AM medications on 03/11/25 were charted as late between 12:37 PM and 12:38 PM.
During an interview on 03/12/25 at 2:15 PM, R3 reported getting medications late or occasionally having medications not available. R3 recalled concerns with medications on 12/18/24 and 12/19/24, and stated she received her 8:00 AM medications around 12:30 PM. R3 stated she received 8:00 AM medications well after 9:00 AM on 03/10/25 and 03/11/25. R3 reported occasionally having chest pain and having to ask for nitroglycerin when her blood pressure medications were not given on time, by 9:00 AM.
During an interview on 03/14/25 at 2:15 PM, the Director of Nursing (DON), who was covering the floor, reported the expectation that medications are administered from an hour before until an hour after the scheduled time.
The DON confirmed the late medication administrations.
525331 03/14/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
time-sensitive medications if she was running behind.
floor, reported the expectation that medications are administered from an hour before until an hour
Review of R3's Face Sheet tab in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. R3 had diagnoses which included pulmonary hypertension, hypertension, and localized edema.
Review of R3's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 02/18/25, located in the EMR RAI [Resident Assessment Instrument] tab, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.
Review of R3's Medication Administration Record (MAR) located in the Reports tab of the EMR for the dates of 12/18/24 to 12/20/24 revealed the following orders:
-hydralazine (vasodilator used to treat high blood pressure) 50 milligrams (mg) three times daily at 8:00 AM, 12:00 PM, and 4:00 PM
-fexofenadine (antihistamine for allergies) 180mg daily at 8:00 AM
-folic acid 1mg daily at 8:00 PM
-liothyronine (thyroid medication) 25 micrograms (mcg) daily at 8:00 AM
-losartan (blood pressure medication) 100mg daily at 8:00 AM
-torsemide (diuretic) 10mg two tabs daily at 8:00 AM
Review of R3's Medications Administration History report provided by the facility for the dates of 12/18/24 to 12/20/24 revealed:
On 12/18/24 the 4:00 PM dose of hydralazine was documented as Not administered: Drug item unavailable.
525331
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525331 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
Review of the Face Sheet tab, located in the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE]. R1 had diagnoses including metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body.)
Review of the Face Sheet tab, located in the EMR, revealed R2 was admitted to the facility on [DATE]. R2 had diagnoses including dementia and anxiety.
Review of a State of Wisconsin Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report submitted to the Department of Health Services on 12/20/24 at 5:22 PM and supplied by the facility revealed R1 reported being backhanded in the face by another resident, R2.
The report stated the event occurred on 12/19/24 around 7:30 PM and was discovered on 12/20/24.
The report stated there were no known witnesses, a head-to-toe skin assessment revealed no injuries, and the resident did not report feeling unsafe.
Investigation is ongoing.
The facility investigative file provided by the Assistant Administrator revealed the facility's former Admissions Director received an email on 12/20/24 from R1's family member (FM)1 of an incident on 12/19/24, initially believed by FM1 to have been between a staff member and R1.
The file stated when the Assistant Administrator interviewed R1, R1 reported R2 yelled at her, Your children are [NAME] along with other comments R1 could not recall as R1 tried to exit her room in her wheelchair.
When R1 told R2 to get away from her, R2 backhanded R1 in the mouth. R2 then rammed her wheelchair into R1's wheelchair as R1 moved away from R2. R1 recalled the events occurring between 7:00 PM and 8:00 PM on 12/19/24 and reported she notified the Registered Nurse (RN) on duty who spoke to R2.
When the Assistant Administrator interviewed R2, R2 could not recall any incident with R1.
The Social Services Director (SSD) completed a Brief Interview of Mental Status (BIMS) on each resident on 12/20/24. R1 scored 10 out of 15, which indicated moderately impaired cognition, and R2 scored two out of 15, which indicated severely impaired cognition.
525331
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525331 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.