Federal inspection record · CMS data as of October 1, 2026
Ingleside Manor
407 N. Eighth St., Mount Horeb, WI · (608) 437-5511
- Special Focus Facility
- Certified beds
- 80
- Residents per day
- 44
- Ownership
- Non-Profit
- Chain
- Wisconsin Illinois Senior Housing, Inc.
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 7, 1983
3
What inspectors found
74 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (6)
-
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Provide enough food/fluids to maintain a resident's health.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care16E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Rights14E
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Reasonably accommodate the needs and preferences of each resident.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Pharmacy Service12E
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure that residents are free from significant medication errors.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure that residents are free from significant medication errors.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure that residents are free from significant medication errors.
Infection Control6F
- F
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- E
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation6D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Nutrition and Dietary5F
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Dispose of garbage and refuse properly.
- F
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration3F
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Resident Assessment and Care Planning3F
- F
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nursing and Physician Services2F
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
- F
Observe each nurse aide's job performance and give regular training.
Environmental1E
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspection history
2025-10-13
15 health deficiencies · 18 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-07-11
49 health deficiencies · 11 fire-safety deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
2023-03-30
10 health deficiencies · 11 fire-safety deficiencies
Top issue: Resident Rights (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 24 min of nursing staff time a day, 54 min of it from a registered nurse.
This home
4 h 24 min
Wisconsin average
4 h 15 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 77% of nursing staff and 83% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$230,869 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-10-13 | Fine | $83,597 |
| 2025-10-13 | Payment Denial · 35 day denial | $0 |
| 2025-06-10 | Fine | $13,273 |
| 2025-06-10 | Fine | $83,656 |
| 2025-06-10 | Payment Denial · 68 day denial | $0 |
| 2024-07-11 | Fine | $36,946 |
| 2023-11-01 | Fine | $13,397 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.2 pts worse | 2.8 | 1.6 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.7 pts better | 1.5 | 2.2 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.7 pts worse | 95.3% | 96.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.9 pts better | 97.5% | 95.6% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.3 pts better | 2.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.1 pts better | 3.9% | 6.0% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.2 pts better | 1.7% | 4.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication2.6 pts better | 14.2% | 16.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication4.1 pts better | 11.8% | 15.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.2 pts worse | 17.2% | 17.0% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased4.5 pts better | 11.3% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.7 pts worse | 3.6% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.7 pts better | 0.0% | 2.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.2 pts better | 22.4% | 23.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers5.2 pts worse | 10.1% | 4.9% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.4 pts better | 90.3% | 86.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visitAbout the same | 15.6% | 15.6% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine13.3 pts better | 95.5% | 82.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.2 pts better | 19.3% | 22.5% | 23.4% |
·
Who owns and runs it
18 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Carriage Healthcare Companies Inc | Operational/Managerial Control · Organization | 0% | 8 facilities |
| Carriage Healthcare Companies Inc | Adp Of The SNF · Organization | 0% | 8 facilities |
| Dupont, Lori | Corporate Director · Individual | 0% | 6 facilities |
| Gehler, Miriam | Corporate Director · Individual | 0% | 7 facilities |
| Hbt It LLC | Adp Of The SNF · Organization | 0% | 6 facilities |
| Jt And Associates LLC | Adp Of The SNF · Organization | 0% | 6 facilities |
| Kerwin, Andrew | Corporate Director · Individual | 0% | 7 facilities |
| Kumar, Rajeev Shiva | Corporate Director · Individual | 0% | 7 facilities |
| Lacke (Carrig), Karen | Corporate Director · Individual | 0% | 5 facilities |
| Lynn, Nicholas | Corporate Director · Individual | 0% | 7 facilities |
| Partners In Wealth Management, Inc | Adp Of The SNF · Organization | 0% | 6 facilities |
| Paszczak, Matthew | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Paszczak, Matthew | Adp Of The SNF · Individual | 0% | 1 facilities |
| Pinion, LLC | Adp Of The SNF · Organization | 0% | 6 facilities |
| Rehab Solutions Group, LLC | Adp Of The SNF · Organization | 0% | 7 facilities |
| Sherman, Stephanie | Operational/Managerial Control · Individual | 0% | 7 facilities |
| Sherman, Stephanie | Adp Of The SNF · Individual | 0% | 7 facilities |
| Twomagnets LLC | Adp Of The SNF · Organization | 0% | 57 facilities |
·
Fire safety
40 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke15F
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Construct fire resistant interior walls.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Gas, Vacuum, and Electrical Systems8F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have power receptacles that are properly grounded.
- E
Ensure proper usage of power strips and extension cords.
- D
Have proper medical gas storage and administration areas.
- D
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- F
Meet requirements for the installation and maintenance of electrical systems.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Services5F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Have properly installed electrical wiring and gas equipment.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Install properly constructed and protected linen or trash chutes.
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous4D
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- C
Have simulated fire drills held at unexpected times.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- D
Have restrictions on the use of portable space heaters.
Emergency Preparedness3F
- F
Develop Emergency Preparedness policies and procedures.
- F
Conduct testing and exercise requirements.
- F
Develop Emergency Preparedness policies and procedures.
Egress3E
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Construction2E
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
·
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