Ingleside Manor
407 N Eighth St · Mount Horeb, WI · 53572 · 6084375511
80 certified beds Non profit - Corporation Chain: Wisconsin Illinois Senior Housing, Inc.
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $186,066 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
$186,066 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
76% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.45 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.13 | 0.55–0.75 |
| Weekend hours / resident-day | 3.87 | ≈ weekday level |
| Nursing turnover / year | 76% | median 45% |
| Fines (3-yr window) | 4 · $199,463 |
Inspection citations (74 in the current record)
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Immediate jeopardy · J October 13, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 16, 2025 · Quality of Life and Care
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Potential for harm · E October 13, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected November 10, 2025 · Resident Rights
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Potential for harm · E October 13, 2025
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.
Corrected November 10, 2025 · Resident Rights
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Potential for harm · E October 13, 2025
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.
Corrected November 10, 2025 · Resident Rights
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Potential for harm · D October 13, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 10, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E October 13, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 13, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 13, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 13, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected November 10, 2025 · Pharmacy Service
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Potential for harm · D October 13, 2025
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.
Corrected November 10, 2025 · Pharmacy Service
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Potential for harm · D October 13, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected November 10, 2025 · Nutrition and Dietary
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Potential for harm · D October 13, 2025
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.
Corrected November 10, 2025 · Administration
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Potential for harm · D October 13, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected November 10, 2025 · Administration
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Potential for harm · F October 13, 2025
Provide and implement an infection prevention and control program.
Corrected November 10, 2025 · Infection Control
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Potential for harm · D October 13, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected November 10, 2025 · Infection Control
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Actual harm · G September 15, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 14, 2025 · Quality of Life and Care
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Potential for harm · D September 15, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected October 14, 2025 · Resident Rights
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Potential for harm · E September 15, 2025 · found via complaint
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.
Corrected October 14, 2025 · Resident Rights
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Potential for harm · D September 15, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 14, 2025 · Quality of Life and Care
-
Potential for harm · D September 15, 2025 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected October 14, 2025 · Quality of Life and Care
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Potential for harm · D September 15, 2025 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected October 14, 2025 · Quality of Life and Care
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Potential for harm · E September 15, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected October 14, 2025 · Pharmacy Service
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Potential for harm · D September 15, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected October 14, 2025 · Pharmacy Service
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Potential for harm · D August 13, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected September 7, 2025 · Resident Rights
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Potential for harm · D August 13, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 13, 2025 | Payment Denial | 35 days |
| June 10, 2025 | Fine | $20,420 |
| June 10, 2025 | Fine | $128,700 |
| June 10, 2025 | Payment Denial | 68 days |
| July 11, 2024 | Fine | $36,946 |
| November 1, 2023 | Fine | $13,397 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525331 · certified since April 7, 1983. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.