Ingleside Manor
INGLESIDE MANOR in MOUNT HOREB, WI — inspection on March 14, 2025.
Found 2 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
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