EDGERTON, WI - Federal regulators documented systematic failures in abuse investigation protocols at Edgerton Care Center following a March 2025 inspection, with multiple residents reporting they were left unchanged in soiled briefs for extended periods overnight without staff response.
Pattern of Inadequate Investigations Documented
State inspectors identified a troubling pattern at the 313 Stoughton Road facility where allegations of potential neglect were logged through the facility's grievance system but failed to receive thorough investigation as required by federal regulations. Between October 2024 and December 2024, at least four separate incidents involving residents left in unhygienic conditions for hours went uninvestigated beyond basic documentation.
The inspection report revealed that while facility staff completed grievance forms for each incident, administrators did not conduct comprehensive investigations that included interviewing witnesses, reviewing staffing patterns, or examining whether similar neglect affected other residents. This pattern contradicted the facility's own policy requiring thorough investigation of all abuse allegations.
Federal regulations mandate that nursing homes must respond to all allegations of abuse, neglect, or mistreatment with complete investigations. The facility's written policy, revised in September 2023, explicitly outlined required investigative steps including interviewing witnesses, reviewing medical records, observing resident-staff interactions, and documenting findings thoroughly.
Residents Report Extended Periods Without Care
One incident from October 28, 2024, involved a cognitively intact resident who required mechanical lift assistance for transfers. According to the inspection narrative, housekeeping staff discovered the resident in her wheelchair in her doorway at approximately 4:10 AM, crying and reporting that no staff had checked on her throughout the night shift.
The resident told the housekeeping manager she had not been transferred to bed and had been sitting in urine, asking "what she did wrong because they wouldn't help her." When the housekeeping manager located nursing staff, a nurse reportedly stated she was "too busy to notice" the resident had never been put to bed. Two certified nursing assistants on duty indicated they had "never seen" the resident before.
The facility's response consisted of a grievance form noting the resident was "very distraught, tired, wet and wanted to get in bed," with resolution listed as "education and more frequent rounds." No investigation documented which staff members were assigned to the resident's care, why assignment protocols failed, or whether other residents experienced similar neglect during that shift.
When inspectors interviewed the resident five months later in March 2025, she recalled the incident clearly, stating she was "tired and scared because she never saw a CNA all night."
Medical Significance of Prolonged Exposure to Moisture
Extended contact between skin and urine creates conditions for moisture-associated skin damage, a preventable medical complication. When skin remains wet for prolonged periods, the outer protective layer softens and becomes more vulnerable to breakdown. Chemical irritants in urine further compromise skin integrity, particularly in elderly individuals whose skin naturally becomes thinner and more fragile with age.
For residents with limited mobility who cannot reposition themselves, the risk intensifies. Pressure combined with moisture creates an environment where skin breakdown can develop within hours rather than days. Once skin integrity is compromised, residents face increased infection risk, pain, and potentially serious medical complications.
Standard nursing practice requires regular toileting assistance—typically every two to three hours—for residents with incontinence. This schedule serves dual purposes: maintaining dignity and preventing medical complications. When facilities fail to provide this basic care, residents experience both physical health risks and psychological distress.
December Incidents Follow Similar Pattern
A second incident on December 15, 2024, involved a resident with mild cognitive impairment who required assistance with transfers and toileting every two to three hours according to her care plan. The resident reported having her call light activated throughout the night, but when a certified nursing assistant finally entered the room, the staff member observed the resident was "soaked in pee all the way up her back," then left the room and closed the door without providing care.
The grievance form documented the resident's statement that she was "scared because the door was shut" and "angry because she was left to lay in her pee all night." The facility's investigation consisted of noting the resident was "upset her needs were not met" and could not identify the specific staff member involved. Resolution listed was "education to staff on rounding and all resident doors are to be open unless cares are being completed."
When interviewed during the inspection, the resident recalled "crying" and feeling "overwhelmed and angry that they weren't taking care of her." No investigation examined staffing assignments, documented response times to call lights, or determined whether system failures contributed to the incident.
A third incident on December 16, 2024, involved a cognitively intact resident who uses a wheelchair and requires extensive assistance with hygiene and dressing. After receiving an enema, the resident reported no staff returned to check on him. Following a bowel movement, he remained in soiled conditions throughout the night until morning shift staff arrived to prepare him for breakfast.
The resident confirmed to inspectors that he "stayed in it all night" and "wasn't cleaned up for several hours until the next morning." The facility's grievance form indicated the care plan would be updated, but no investigation explored why nighttime nursing staff failed to provide follow-up care after administering the enema.
Clinical Protocols for Bowel Care
Medical protocols for enema administration require monitoring and follow-up care. When healthcare providers administer medications or treatments designed to stimulate bowel movements, they assume responsibility for managing the results. Standard practice involves checking on patients within a reasonable timeframe—typically 30 minutes to one hour after administration—to provide necessary hygiene assistance.
Leaving a resident in fecal matter for hours violates basic care standards and creates multiple health risks. Prolonged contact with stool increases infection risk, particularly for residents with compromised immune systems or existing health conditions. The chemical composition of feces is more irritating to skin than urine, accelerating potential skin breakdown.
Beyond physical health implications, this type of neglect affects residents' psychological wellbeing and sense of dignity. Research on nursing home quality consistently identifies responsive toileting assistance as fundamental to resident satisfaction and quality of life.
November Incident Involves Alleged Staff Misconduct
An incident on November 13, 2024, combined potential neglect with alleged inappropriate staff behavior. A resident with mild cognitive impairment and multiple chronic conditions reported that three staff members turned him in bed without changing his brief. When he contacted a nurse to report he had not been changed, a certified nursing assistant allegedly returned to his room and "waved his wet brief in his face," stating "Look! I wouldn't not change you."
The facility's investigation consisted of asking the resident to describe the staff member, noting she had "a lot of hair on top of her head," and listing resolution as "Agency CNA DNR (Do Not Return)." No documentation indicated interviews with the three staff members who initially provided care, the nurse the resident contacted, or other residents receiving care from the identified agency worker.
Regulatory Requirements for Abuse Investigations
Federal regulations require nursing homes to establish and maintain systems that prevent, identify, investigate, and respond to allegations of abuse and neglect. When facilities receive reports of potential mistreatment, administrators must conduct thorough investigations that include specific elements: reviewing documentation and medical records, observing the alleged victim, interviewing the person reporting the incident, interviewing witnesses, speaking with the resident when medically appropriate, consulting with physicians as needed, interviewing staff from all shifts who had contact with the resident, and documenting findings completely.
The facility's own policy, revised September 2023, outlined these exact requirements. The policy specified that administrators are "responsible for determining what actions (if any) are needed for the protection of the residents" and that "all allegations are thoroughly investigated."
During the inspection, the facility's social worker—who serves as grievance officer but was not employed during the incidents in question—reviewed the grievance forms and stated she would have considered these incidents as allegations of potential abuse requiring investigation. She described her standard practice as speaking with the resident, floor staff, and the previous shift, then following up with residents to provide status updates and ensure satisfaction with resolution.
The administrator acknowledged to inspectors that the incidents documented in the grievance forms represented potential neglect allegations. When asked if thorough investigations had occurred, the administrator responded that while they "followed through on them," they "didn't have a file or documentation on them" and stated the incidents "should have been reported and investigated."
Additional Issues Identified
Beyond the four main incidents involving residents left in soiled briefs without assistance, inspectors documented two additional allegations that received inadequate investigation. During a November 25, 2024, care conference, a family member raised an abuse allegation that the facility did not investigate. Additionally, on November 28-29, 2024, a night shift certified nursing assistant discovered a resident who was "bright red and shaking with fresh blood on his right forearm" from a skin tear, with the resident alleging that agency staff "wouldn't let him get up and held his hands down." The facility did not thoroughly investigate this allegation of physical restraint or provide training to prevent similar incidents.
The inspection findings affect both current residents and broader facility operations. When nursing homes fail to investigate abuse allegations thoroughly, they cannot identify system failures, provide staff training to prevent recurrence, or ensure other residents are not experiencing similar mistreatment. The pattern documented at Edgerton Care Center suggests gaps in nighttime staffing oversight, assignment protocols, and supervisory systems designed to ensure residents receive basic care.
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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