Edgerton Care Center: Catheter Order Gaps Found - WI
"Yes," she told the inspector. There should have been an order for it.
A March 31, 2025 inspection of Edgerton Care Center found that the facility had no active physician order specifying the size of the Foley catheter in place for a resident identified in inspection records as Resident 28, nor the amount of fluid required to inflate the catheter balloon. The Director of Nursing, identified in the report as DON B, confirmed both gaps during an interview with the surveyor that morning.
A Foley catheter is a tube inserted through the urethra into the bladder to drain urine. The balloon at the tip is inflated with a specific amount of sterile water once the catheter is in place, holding it there. The size of the catheter, measured in French units, and the balloon fill volume are not interchangeable between devices. Using the wrong size or filling the balloon incorrectly carries risk of injury to the bladder and urethra.
Resident 28 had been living with a Foley catheter since at least September 2024. The physician orders on file were detailed in many respects. They specified catheter care twice daily, at 6:30 in the morning and again at 2:30 in the afternoon. They required the drainage bag be changed every 30 days, between the third and seventh of each month. A securement device was to be checked three times a day and replaced every Monday. Output was to be recorded every shift. Staff were authorized to flush the catheter with 60 milliliters of sterile saline up to three times a day as needed to keep it clear.
What the orders did not contain, as of the day of inspection, was any active directive stating what size catheter belonged in this resident or how much fluid should go into the balloon.
The inspection report notes two historical orders that touched on catheter changes. One, dated March 11, 2025, directed staff to change the Foley catheter to a 16 French size with a 10 milliliter balloon. That order was a one-time directive, opening and closing on the same date. A second order, dated March 23, 2025, instructed staff to change the catheter because it was occluded. That order also opened and closed the same day. Inspectors noted specifically that this second order did not reference the previous catheter size or specify what size should be inserted as a replacement.
After March 23, there was nothing in the active orders to tell staff what catheter was in place.
The facility's own orders required staff to monitor Resident 28 for signs of urinary tract infection, a standing directive that had been in place since September 2024. That order listed the symptoms to watch for: acute confusion, urgency, frequency, burning, pain, nausea, chills, fever, low back or flank pain, foul odor, concentrated urine, blood in urine. Staff were expected to recognize those signs and report them.
Whether anyone noticed anything to report, the inspection record does not say.
The surveyor asked DON B directly, at 11:41 on the morning of March 31, what size catheter Resident 28 was supposed to have. DON B looked. She did not find an answer in the chart. She agreed that an order specifying the size should exist.
The inspection classified the deficiency as having the potential for minimal harm or actual harm to a small number of residents. Edgerton Care Center is located at 313 Stoughton Road in Edgerton, Wisconsin.
Resident 28 remained a catheter-dependent resident on the day inspectors walked out the door, with a device inside them whose size no active order in their medical record could confirm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edgerton Care Center, Inc from 2025-03-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 28, 2026 · Our methodology
Edgerton Care Center, Inc in Edgerton, WI was cited for violations during a health inspection on March 31, 2025.
There should have been an order for it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.