Ingleside Manor
INGLESIDE MANOR in MOUNT HOREB, WI — inspection on September 15, 2025.
Found 8 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
indicated she enjoys eating with her tablemates and talking with them. R6 indicated staff do not take her to the dining room for all her meals and will give R6 her meal tray in her room.On 9/11/25 at 9:28 AM, CNA D (Certified Nursing Assistant) entered R6's room and asked R6 if she was ready to take her shower.Of note, R6 did not have breakfast in the dining room on 9/11/25 due to the delay in the timing of her shower.R6's CNA work sheet indicates R6 goes to the dining room for meals.R6's meal tickets, printed 9/11/25, state Main DR (dining room) Table (number).On 9/11/25 at 1:30 PM, Surveyor interviewed DM C (Dietary Manager) regarding R6's meal ticket. DM C stated R6 prefers to eat in the dining room, and it is marked on R6's meal ticket.On 9/11/25 at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding R6's preference to eat in the dining room for her meals. DON B indicated it is the resident's right to eat where they choose. DON B indicated staff should honor R6's choice to eat in the dining room.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor
407 N Eighth St Mount Horeb, WI 53572
SUMMARY STATEMENT OF DEFICIENCIES
may have spilled. CNA D identified the brown matter on the outside of the toilet bowl as “poop”. CNA D indicated the room was not clean.
On 9/11/25 at 11:27 AM, Surveyor observed R6's room. R6's room still had the crumbs, dried liquid, and crusty brown flaky circles on the floor and the toilet still had the brown matter on the outside of it.
Surveyor also observed two bags of trash outside of R6's bathroom door on her bedroom floor.
One trash bag contained linen, the other bag contained dirty personal protective equipment (gloves, gowns and other trash).
On 9/11/25 at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding the cleanliness in R6's room.
Surveyor made DON B aware of the above observations. DON B indicated R6's room was not clean and should be.
On 9/11/25 at 4:00 PM, Surveyor observed R6's room.
The outside of the toilet had been cleaned and R6's floor had been mopped.
The two trash bags still remained on the floor outside of R6's bathroom door.
Example 2 On 9/11/25 at 9:15 AM, Surveyor interviewed R4.
Surveyor asked R4 how often they clean her room. R4 indicates staff come in to clean her room once a week if she is lucky.
Example 3 On 9/11/25 at 9:10 AM, Surveyor interviewed R13.
Surveyor asked R13 how often housekeeping comes in to clean her room. R13 states, my room is not cleaned daily. I am not sure I can say it is even cleaned weekly.
Surveyor noted R13 had debris on floor and floor appeared as it had not been cleaned in some time.
On 9/11/25 at 9:30 AM, Surveyor interviewed R12.
Surveyor asked R12 how often housekeeping comes in to clean his room. R12 states, my room is not cleaned daily and only has been cleaned once in the last month.
Surveyor noted R12 had fly strip hanging on wall next to bed.
Room was dusty and floor appears to have debris on it from food and fluids.
On 9/15/25 at 8:45 AM, Surveyor interviewed CNA O.
Surveyor asked CNA O how often resident rooms are cleaned. CNA O stated that they are not always able to get to all rooms in a day.
On 9/15/25 at 11:15 AM, Surveyor interviewed HS N (Housekeeping Supervisor).
Surveyor asked HS N if she has any staffing concerns in her department. HS N stated, we don't have enough staff to get it all done.
If rooms are not done, will communicate verbally what was not done and it will be completed the next day.
Surveyor asked HS N if she meets with residents to see if they have concerns. HS N states that the new Activities Manager does not bring other departments into resident council to listen to resident concerns. If there are concerns the Activities Manager will bring the issue or concern to the department to be addressed.
The facility did not ensure each resident had a safe, clean, comfortable, and homelike environment
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor
407 N Eighth St Mount Horeb, WI 53572
SUMMARY STATEMENT OF DEFICIENCIES
The facility failed to complete ongoing comprehensive wound assessments throughout her stay, that included characteristics of the wound such as the type of wound, wound bed description, appearance of the surrounding tissue, if there was drainage or odor.
While at the facility, R2's wound increased in size and developed a foul odor. No physician notification was made regarding these changes timely and R2 was readmitted to the hospital with a diagnosis of a wound infection.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor
407 N Eighth St Mount Horeb, WI 53572
SUMMARY STATEMENT OF DEFICIENCIES
R6's cushion not being in the recliner and R6's bed being set to static. DON B indicated R6's bed should be on pulsate and R6 should have a cushion in her recliner. DON B indicated R6's interventions were not being followed for pressure injury prevention and should be.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor
407 N Eighth St Mount Horeb, WI 53572
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review, the facility did not ensure that a resident with urinary catheters receive appropriate treatment and services for 1 of 1 residents (R6) reviewed for catheters as catheter bags were observed resting on the floor.Surveyor observed R6's urinary catheter bag resting on the floor.This is evidenced by:The facility's policy titled Catheter Care, Urinary, dated 9/14, includes: The purpose of this procedure is to prevent catheter-associated urinary tract infections.
Infection control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor.R6's active physician orders, dated 9/11/25, include: SP Catheter (Suprapubic Catheter, a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen): cleanse daily with mild soap and water; pat dry with soft towel.R6's resident profile sheet, printed 9/11/25, is used by the CNAs (Certified Nursing Assistant) and includes: indwelling catheter: do not allow tubing or any part of the drainage system to touch the floor.R6's comprehensive care plan, printed 9/11/25, includes:Problem: Indwelling catheter.
Resident requires a suprapubic catheter.Goal: Resident will have suprapubic catheter care managed appropriately as evidenced by: not exhibiting obstruction, signs of infection, dislodgement of catheter, bowel perforation, or trauma.
Approach: Do not allow tubing or any part of the drainage system to touch the floor.On 9/11/25 at 8:30 AM, Surveyor interviewed R6. R6 was sitting in her recliner in her room.
Surveyor observed R6's catheter tubing and drainage bag sitting on the floor next to R6's recliner. R6 indicated she has a history of urinary tract infections and was concerned with the care she receives for her catheter tubing and drainage bag.On 9/11/25 at 9:28 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding R6's catheter tubing and drainage bag. CNA D indicated R6's catheter tubing and drainage bag should not be on the floor. CNA D moved R6's catheter tubing and drainage bag off the floor.On 9/11/25 at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding placement of catheter tubing and drainage bags. DON B Indicated tubing and drainage bags should be hung below the level of the resident's bladder and should not be placed on the floor.
Surveyor made DON B aware of surveyor's observation of R6's catheter tubing and drainage bag being on the floor. DON B indicated R6's catheter tubing and drainage bag should not have been on the floor.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor
407 N Eighth St Mount Horeb, WI 53572
SUMMARY STATEMENT OF DEFICIENCIES
The facility failed to ensure a care plan was developed that included precautions and monitoring for a resident with a history of several suicide attempts in the past.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor
407 N Eighth St Mount Horeb, WI 53572
SUMMARY STATEMENT OF DEFICIENCIES
administration. DON B indicated if medication is not administered timely, it is considered a medication error.
DON B indicated since R6 had not yet received her 8:00 AM medications at 10:46 AM it is considered a medication error for those medications. DON B indicated medications should be administered timely and R6's was not.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingleside Manor
407 N Eighth St Mount Horeb, WI 53572
SUMMARY STATEMENT OF DEFICIENCIES
Mycophenolate sodium (Immunosuppressant agent to prevent organ rejection in transplant patients) tablet; delayed release (DR/EC (Delayed Released/Enteric Coated)); 360 mg; amt: 1 tablet; oral.
Twice A Day; 8:00 AM, 8:00 PM.
Start Date: 8/20/25.
End Date: Open Ended.
On 8/20/25 at 8:00 PM: Space left blank, indicating the medication was not administered.
On 8/22/25 at 8:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” On 9/5/25 at 8:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” The facility's medication contingency supply list includes: Levetiracetam 250 MG; QOH (Quantity On Hand) 10 each On 9/15/25 at 3:08 PM, Surveyor interviewed DON B.
Surveyor noted that R3 did not receive some of her medications from 8/20/25-8/23/25, including her Lacosamide, Insulin Aspart, Levetiracetam, and Mycophenolate.
Surveyor asked DON B if she would have expected these medications to be administered as ordered. DON B indicates, yes, and that pharmacy sends two delivers during the day to deliver medications.
Surveyor asked DON B if she would consider these medications that were not administered to be medication errors. DON B indicates, yes.
Surveyor asked DON B if these medications are in contingency, would she expect staff to pull the medication from contingency to administer to the resident.
DON B indicates, yes.
Facility ID: