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
due to the delay in the timing of her shower.R6's CNA work sheet indicates R6 goes to the dining room
prefers to eat in the dining room, and it is marked on R6's meal ticket.On 9/11/25 at 3:33 PM,
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.
525331 09/15/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
“poop”. CNA D indicated the room was not clean.
and crusty brown flaky circles on the floor and the toilet still had the brown matter on the outside of
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
525331 09/15/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
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.
525331 09/15/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
consistent with professional standards of practice, to prevent pressure injuries (PI) for 1 of 1
prevention devices were observed not in place.This is evidenced by:The facility's policy Prevention of Pressure Injuries, dated 4/20, includes: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors.
Use a standardized pressure injury screening tool to determine and document risk factors.
Select appropriate support surfaces based [sic] the resident's risk factors, in accordance with current clinical practice.The facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 4/18, includes: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document report the following: d.
Current treatments, including support surfaces.
The physician will order pertinent wound treatments, including pressure reduction surfaces. R6 admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of the nerves), cerebral infarction (occurs when blood flow to the brain is interrupted, leading to cell death and brain damage), major depressive disorder (a mood disorder characterized by persistent feelings of sadness and hopelessness), muscle weakness (decreased strength in muscles), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).R6's 8/24/25 Braden Scale for Predicting Pressure Score Risk assessment indicates R6 is at risk for pressure injury.R6's comprehensive person-centered care plan, printed on 9/11/25, includes:Problem: Start date: 8/11/25.
Pressure ulcer/injury. R6 presented with a stage 2 pressure injury to her coccyx.
Approach: Consider specialty mattress or bed.
Elevate heels and use protectors.
Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair.
Consider specialty chair pad.R6's active physician orders, printed 9/11/25, include:Must be on pulsate mattress.
Use pressure offloading cushion (waffle or roho) when up in chair.
Must reposition every 30 minutes while up.R6's Resident Profile sheet, used by CNAs (Certified Nursing Assistant), to guide care does not include any pressure relieving interventions.On 9/11/25 at 8:30 AM, Surveyor interviewed R6. R6 was sitting in her recliner, there was no cushion in the recliner.
Surveyor observed a cushion in R6's wheelchair.
Surveyor observed R6 had a specialty mattress.
The settings on the mattress were set to static. R6 indicated she had a pressure injury on her buttocks.
Surveyor was in R6's room until 9:28 AM.
Surveyor did not observe facility staff encourage or offer R6 to reposition during the 58 minutes surveyor was in the room.On 9/11/25 at 9:28 AM, Surveyor interviewed CNA D about resident care needs for R6. CNA D indicated the CNAs use a sheet that includes pertinent information about the residents. Of note, the sheet being used by the CNAs does not include any pressure injury prevention interventions.On 9/11/25 at 3:59 PM, Surveyor interviewed CNA H regarding resident care needs for R6. CNA H indicated the resident's Resident Profile sheet would state how to care for a resident.
Surveyor asked where the CNAs would find pressure injury interventions and CNA H indicated on the Resident Profile sheet.Of note, R6's Resident Profile does not include any pressure injury prevention interventions.On 9/11/25, Surveyor interviewed DON B (Director of Nursing) regarding R6's pressure injury. DON B indicated R6 has a stage 2 pressure injury on her buttocks. DON B indicated R6 should have a pulsating mattress and cushion when up in her chair. DON B indicated staff should ensure the pressure injury prevention devices are in place.
Surveyor informed DON B of the observations Surveyor made of 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.
525331 09/15/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
catheter care, and appropriate care to prevent urinary tract infections.
urinary catheters receive appropriate treatment and services for 1 of 1 residents (R6) reviewed for
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.
525331 09/15/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
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.
525331 09/15/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
is considered timely if the medication is administered between 7:00 AM and 9:00 AM.
On 9/11/25 at 4:03 PM, Surveyor interviewed LPN F regarding medication administration. LPN F indicated if medication is administered outside of the 2-hour window it is considered a medication error.
On 9/11/25 at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding medication 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.
525331 09/15/2025
Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572
Start Date: 8/20/25. D/C Date: 8/21/25.
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.
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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.