EDGERTON, WI - Federal inspectors cited Edgerton Care Center for failing to immediately report abuse allegations and protect vulnerable residents following a November 2024 incident involving a dementia patient who sustained unexplained injuries during the night shift.
The Wisconsin nursing home received violations for not following proper reporting protocols when a resident with moderate cognitive impairment reported being harmed and was found with fresh blood on his arm and bedding at approximately 2:00 AM.
Critical Reporting Protocol Failures
The inspection revealed significant breakdowns in the facility's abuse reporting system. When a certified nursing assistant discovered the injured resident, she only left a voicemail message for the nursing home administrator at 1:54 AM rather than ensuring immediate contact as required by federal regulations.
The administrator did not learn about the incident until the Director of Nursing contacted her during shift change hours later. This delay violated federal requirements that mandate immediate reporting of suspected abuse or neglect incidents in nursing homes.
The injured resident had been diagnosed with dementia, generalized anxiety disorder, and major depressive disorder. His care plan documented that he could become combative during care and had a history of verbal and physical aggression toward staff when resisting assistance with daily activities.
Inadequate Staff Response During Critical Incident
During the incident, three staff members were working the night shift: one regular certified nursing assistant and two agency workers - a CNA and licensed practical nurse. The regular CNA discovered the resident calling for help and found fresh blood on his right forearm and bedding.
When the licensed practical nurse entered the room, the resident reportedly told her to leave. The CNA attempted to bring in the agency CNA, but the resident also refused her assistance. Only the regular CNA was permitted to clean the wound with a cold washcloth.
The facility's care plan specifically outlined approaches for managing the resident's resistance to care, including stopping care activities if he became combative, ensuring his safety, leaving the room, and reapproaching at a later time. However, the inspection found failures in protecting the resident and reporting the incident properly.
Federal Regulations Require Immediate Action
Nursing homes must comply with strict federal regulations designed to protect vulnerable residents from abuse and neglect. Under 42 CFR 483.12, facilities must immediately report any suspected abuse to the administrator and take steps to protect residents from further harm.
The regulations require that when staff discover potential abuse situations, they cannot simply leave voicemail messages and continue with routine duties. Staff must persistently attempt contact with administrators until reaching someone who can authorize protective measures and initiate proper investigations.
Federal guidelines emphasize that residents with cognitive impairments, like dementia patients, require enhanced protections due to their vulnerability and potential inability to advocate for themselves effectively.
Administrator Acknowledges Protocol Violations
During the inspection interview, the nursing home administrator confirmed that staff should immediately contact her when residents report abuse and sustain injuries. She acknowledged that residents must be protected and that the incident should have been reported immediately rather than through a voicemail message.
The administrator stated that the CNA "should have called back again and tried the Director of Nursing as well." She explained that staff must continue calling administrators until reaching someone, and that administrators will notify each other about critical incidents.
The administrator noted that the CNA believed she had properly reported the incident by leaving the voicemail message, highlighting a dangerous gap in staff understanding of emergency reporting requirements.
Pattern of Care Challenges
The resident's comprehensive care plan revealed ongoing challenges with behavioral symptoms and resistance to care. Documentation showed he had been combative during care activities and experienced hallucinations related to his cognitive impairment.
His care plan included specific interventions such as providing a quiet, low-stimulation environment and offering activities like solitaire when he was awake at night. The plan also documented frequent refusals to get out of bed and patterns of verbal and physical aggression toward staff.
The resident had been at the facility since October 2021 before discharging in December 2024. He passed away after leaving the facility, underscoring the importance of proper care protocols during his vulnerable final months.
Required Corrective Measures
The inspection findings mandate immediate corrective action by Edgerton Care Center. The facility must implement comprehensive staff education regarding proper reporting procedures and resident protection protocols.
All staff require training on when and how to report suspected abuse incidents, emphasizing that voicemail messages alone are insufficient for emergency situations. The facility must establish clear escalation procedures ensuring administrators receive immediate notification of critical incidents.
Training must specifically address the prohibition against physical restraints and proper techniques for managing residents who resist care. Staff need education on de-escalation strategies and when to withdraw from situations while ensuring resident safety.
Protecting Vulnerable Populations
This case highlights the critical importance of robust protective systems in nursing homes, particularly for residents with cognitive impairments who may be unable to advocate for themselves effectively. Dementia patients require enhanced monitoring and protection due to their vulnerability to exploitation and abuse.
The incident underscores why federal regulations mandate immediate reporting and response protocols. Delays in addressing potential abuse situations can result in continued harm to vulnerable residents and compromise facility-wide safety systems.
Proper implementation of abuse prevention protocols protects not only individual residents but maintains the integrity of care quality throughout the facility. When staff understand and follow reporting requirements, it creates a culture of safety and accountability that benefits all residents.
The violations at Edgerton Care Center demonstrate the ongoing need for vigilant oversight and training in nursing home facilities to ensure vulnerable residents receive the protection and care they deserve under federal law.
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.
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