Wisconsin ›Mount Horeb

Ingleside Manor

407 N Eighth St, Mount Horeb, WI 53572 · Dane County · 80 certified beds · avg 40 residents/day · certified since Apr 7, 1983

SFF

Part of chain: WISCONSIN ILLINOIS SENIOR HOUSING, INC. (7 facilities, chain avg rating 1.7★)

—/5
Health inspection rating (on-site)
6
Serious findings on record
$283,060
Fines, last 3 years
4.15
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: —/5 · CMS overall rating: —/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Oct 13, 2025 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Dec 16, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Jul 9, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Aug 6, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Jul 9, 2025 · F-0692 · triggered by a complaint

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Aug 6, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 15, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 14, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jul 11, 2024 · F-0684

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Aug 5, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Nov 1, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 27, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (74)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Oct 13, 2025▲ J · Immediate jeopardy, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Oct 13, 2025F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 13, 2025E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Oct 13, 2025E · Potential for harm, repeatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Oct 13, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Oct 13, 2025E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Oct 13, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Oct 13, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Oct 13, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Oct 13, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Oct 13, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Oct 13, 2025D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Oct 13, 2025D · Potential for harm, one-offThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Oct 13, 2025D · Potential for harm, one-offThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Oct 13, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Sep 15, 2025▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 15, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Sep 15, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Sep 15, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Sep 15, 2025D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Sep 15, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Sep 15, 2025D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Sep 15, 2025D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Aug 13, 2025E · Potential for harm, repeatedThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Aug 13, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jul 9, 2025▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 9, 2025▲ J · Immediate jeopardy, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Jul 9, 2025F · Potential for harm, facility-wideThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jul 9, 2025F · Potential for harm, facility-wideThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint
Jul 9, 2025F · Potential for harm, facility-wideThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint
Jul 9, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jul 9, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jul 9, 2025D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint
Jul 9, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jun 10, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 14, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Mar 14, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 14, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Mar 14, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Mar 14, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint
Jul 11, 2024▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 11, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 11, 2024F · Potential for harm, facility-wideThe facility did not dispose of garbage and refuse properly.
Jul 11, 2024F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 11, 2024E · Potential for harm, repeatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jul 11, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jul 11, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jul 11, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 11, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jul 11, 2024D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jul 11, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jul 11, 2024D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Jul 11, 2024D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jul 11, 2024D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Jul 11, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Nov 1, 2023▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 30, 2023F · Potential for harm, facility-wideThe facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times.
Mar 30, 2023F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 30, 2023E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Mar 30, 2023E · Potential for harm, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Mar 30, 2023E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 30, 2023D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 30, 2023D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Mar 30, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Mar 30, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (15 → 15).

YearCitationsSerious (G–L)Worst severity that year
2023101G ▲
2024151G ▲
2025494J ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

5 fines totaling $283,060, plus 2 Medicare payment denial periods.

DateTypeAmount / length
Oct 13, 2025Fine$83,597
Oct 13, 2025Payment Denial35 days from Nov 11, 2025
Jun 10, 2025Fine$20,420
Jun 10, 2025Fine$128,700
Jun 10, 2025Payment Denial68 days from Aug 7, 2025
Jul 11, 2024Fine$36,946
Nov 1, 2023Fine$13,397

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityWisconsin avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.154.293.95top 48% in Wisconsin; top 34% in the U.S.
Registered Nurse hours1.061.010.69top 38% in Wisconsin; top 13% in the U.S.
Weekend total nurse staffing3.593.843.50bottom 45% in Wisconsin; top 38% in the U.S.
Weekend RN hours (not acuity-adjusted)0.770.680.48top 32% in Wisconsin; top 13% in the U.S.
Total nursing staff turnover (%)80.646.945.8bottom 1% in Wisconsin; bottom 2% in the U.S.
RN turnover (%)75.039.742.9bottom 6% in Wisconsin; bottom 9% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.15, RN 1.06, weekend 3.59. Staffing rating: —/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5

Who owns this facility

Non profit - Corporation

Owner / managerTypeRoleStakeSince
Carriage Healthcare Companies INCOrganizationOperational/Managerial ControlNOT APPLICABLE08/09/2012
Carriage Healthcare Companies INCOrganizationADP of the SNFNOT APPLICABLE10/06/2025
Dupont, LoriIndividualCorporate DirectorNOT APPLICABLE01/25/2016
Gehler, MiriamIndividualCorporate DirectorNOT APPLICABLE01/01/2017
HBT It LLCOrganizationADP of the SNFNOT APPLICABLE07/01/2024
JT and Associates LLCOrganizationADP of the SNFNOT APPLICABLE01/01/2010
Kerwin, AndrewIndividualCorporate DirectorNOT APPLICABLE06/26/2009
Kumar, Rajeev ShivaIndividualCorporate DirectorNOT APPLICABLE04/24/2012
Lacke (carrig), KarenIndividualCorporate DirectorNOT APPLICABLE01/01/2016
Lynn, NicholasIndividualCorporate DirectorNOT APPLICABLE03/14/2011
Partners in Wealth Management, INCOrganizationADP of the SNFNOT APPLICABLE01/01/2024
Paszczak, MatthewIndividualOperational/Managerial ControlNOT APPLICABLE03/05/2023
Paszczak, MatthewIndividualADP of the SNFNOT APPLICABLE03/05/2023
Pinion, LLCOrganizationADP of the SNFNOT APPLICABLE01/01/1995
Rehab Solutions Group, LLCOrganizationADP of the SNFNOT APPLICABLE01/01/2024
Sherman, StephanieIndividualOperational/Managerial ControlNOT APPLICABLE08/12/2012
Sherman, StephanieIndividualADP of the SNFNOT APPLICABLE08/12/2012
Twomagnets LLCOrganizationADP of the SNFNOT APPLICABLE01/01/2022

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 525331.