Ingleside Manor
Mount Horeb, Wisconsin · CCN 525331
23 surveys since 2011, 11 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 114
- Surveys
- 23
- Harm or worse
- 11
- Immediate jeopardy
- 3
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 80
- Ownership
- Non profit - Corporation
- Chain
- WISCONSIN ILLINOIS SENIOR HOUSING, INC.
- County
- Dane
- Medicare-certified since
- 1983
CMS ratings
- Overall
- —
- Health inspection
- —
- Staffing
- —
- Quality measures
- —
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 20 not-for-profit facilities of 66–99 beds in Wisconsin.
Last survey on record
Oct 13, 2025
392 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.15 | 4.33 |
| Registered-nurse hours per resident day | 1.06 | — |
| Annual nurse turnover | 80.6% | 49.2% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $283,060 across 5 penalties
- Payment denials
- 2
- Special focus
- SFF
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J34.1% | K— | L— |
| Actual harm | G34.1% | H— | I— |
| No harm, potential for more than minimal | D4763.5% | E1216.2% | F912.2% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6895×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F5804×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F6094×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6844×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6924×
Provide enough food/fluids to maintain a resident's health.
In the surveyor’s words
From the most serious findings on record at Ingleside Manor, in the surveyor’s own words.
- Immediate jeopardy, isolatedF686Oct 13, 2025
Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 2 of 6 residents (R28 and R4) reviewed for PIs out of a sample of 19 residents. R28 was admitted to the facility with four (4) Stage 1 PIs. R28 was at risk for further PI development and had significant comorbidities. The facility failed to complete a readmission skin assessment, accurately complete all wound assessments and measurements, notify the provider of changes to the PI, offload pressure, and follow standards of practice during wound care. […]
- Immediate jeopardy, isolatedF689Jul 9, 2025
Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R6) reviewed for elopement, 2 of 3 residents (R8 and R10) who smoke, 1 of 1 resident’s (R18) who voiced suicidal ideations, and 1 of 3 residents (R13) at risk for falls. The facility’s failure to supervise a resident who was known to be an elopement risk, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 4:19 PM. […]
- Immediate jeopardy, isolatedF692Jul 9, 2025
Based on observation, interview, and record review, the facility failed to ensure a resident who receives assisted nutrition and hydration maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 4 residents (R14) reviewed for nutrition and hydration.R14 has diagnoses including severe protein malnutrition, severe weight loss, and adult failure to thrive (FTT). R14 was admitted to the facility on [DATE]. R14's discharge physician orders included an order indicating NPO (Nothing by Mouth). R14 was to receive enteral feedings. […]
- Actual harm, isolatedF684Sep 15, 2025
Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 4 sampled residents (R2). R2 was admitted to the facility with a wound on her left abdomen. The facility failed to complete ongoing comprehensive wound assessments throughout her stay. While at the facility, R2's wound increased in size and developed a foul odor. No physician notification was made. R2 was readmitted to the hospital with a diagnosis of a wound infection. Evidenced by:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. […]
- Actual harm, isolatedF684Jul 11, 2024
Based on interview and record review, the facility did not ensure that a resident received treatment and care to prevent hospitalization in accordance with professional standards of practice for 1 of 6 residents (R18) that were reviewed for hospitalization s out of a total sample of 16. R18 had a change in condition and the facility did not complete full assessments and monitor symptoms. R18's condition continued to decline and R18 was hospitalized with atrial flutter (an abnormal heart rhythm in the heart's upper chambers (atria) when the atria beats too fast. […]
Read 29 findings in full →The most serious and the most recent: 29 of 114 on record.
Every survey on record
FindingsAt actual harm or above
- Oct 13, 2025Standard15 findings · 1 harm
- Sep 15, 2025Complaint8 findings · 1 harm
- Aug 13, 2025Complaint11 findings
- Jul 9, 2025Complaint9 findings · 2 harm
- Jun 10, 2025Complaint1 finding
- Mar 14, 2025Complaint5 findings
- Jul 11, 2024Standard15 findings · 1 harm
- Nov 1, 2023Complaint1 finding · 1 harm
Show the 15 earlier surveys
- Mar 30, 2023Standard and complaint9 findings
- Oct 31, 2022Complaint3 findings
- Mar 1, 2022Complaint1 finding · 1 harm
- Jan 12, 2022Complaint1 finding · 1 harm
- Dec 1, 2021Standard3 findings
- Sep 22, 2021Complaint2 findings
- Jun 15, 2021Complaint1 finding
- Oct 1, 2019Standard4 findings · 1 harm
- Nov 9, 2017Standard2 findings
- Oct 26, 2016Standard3 findings
- Sep 16, 2015Standard2 findings
- Aug 12, 2014Standard6 findings · 1 harm
- Jul 11, 2013—4 findings
- Jun 1, 2012—4 findings · 1 harm
- Apr 12, 2011—4 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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