EDGERTON, WI - Federal inspectors cited Edgerton Care Center for failing to conduct thorough investigations into serious allegations of physical restraint and neglect affecting multiple residents during a March 2025 inspection.
Physical Restraint Allegations Go Uninvestigated
The most serious incident involved a resident who reported being physically restrained by staff members during an overnight shift. On November 28-29, 2024, a nursing assistant discovered the resident "bright red and shaking with fresh blood on his right forearm" from a skin tear. The resident told staff that agency workers "wouldn't let him get up and held his hands down."
Despite the serious nature of the allegation involving physical restraint - which violates federal nursing home regulations - the facility failed to conduct a comprehensive investigation as required by their own policies. The incident occurred when agency staff were working the overnight shift, raising concerns about oversight of temporary workers.
Physical restraint of nursing home residents is prohibited except in very limited circumstances to prevent immediate physical harm, and must be ordered by a physician with strict time limitations. Holding down a resident who is attempting to get up does not meet these criteria and constitutes abuse under federal regulations.
Pattern of Inadequate Care Investigations
The federal inspection revealed a troubling pattern of incomplete investigations into resident care complaints spanning several months:
October 2024: A cognitively intact resident was discovered at 4:10 AM by housekeeping staff, crying in her wheelchair after being left in the hallway all night. The resident reported that no staff had checked on her or assisted her to bed, leaving her sitting in wet clothing. Two nursing assistants on duty claimed they had "never seen" the resident before, despite her being a facility resident.
December 2024: Another resident reported having her call light activated all night while lying in soiled bedding. When staff finally responded, they acknowledged she was "soaked in pee all the way up her back" but left the room and closed the door without providing care. The resident described feeling scared and abandoned.
December 2024: A resident with bowel incontinence was given an enema but left unattended afterward. He remained in soiled conditions for hours until the morning shift arrived to prepare him for breakfast.
November 2024: A resident with mild cognitive impairment reported that staff waved his wet brief in his face after he complained about not being changed, with the aide saying "Look! I wouldn't not change you."
Investigation Standards Not Met
Federal regulations require nursing homes to thoroughly investigate all allegations of abuse, neglect, or mistreatment. The facility's own policy, revised in September 2023, mandates comprehensive investigations that include interviewing witnesses, reviewing medical records, and documenting findings completely.
However, inspectors found the facility only completed basic grievance forms for each incident without conducting the required thorough investigations. None of the cases involved interviewing other residents or staff members who might have witnessed similar problems or could provide additional information about care practices.
This investigative failure represents a significant breakdown in resident protection systems. Thorough investigations serve multiple purposes: they determine what actually occurred, identify system failures that allowed problems to develop, and prevent similar incidents through corrective actions and staff training.
Medical and Safety Implications
The documented incidents reveal serious gaps in basic nursing care that can lead to significant health complications:
Prolonged immobilization in wheelchairs can cause pressure sores, blood clots, and muscle contractures. Leaving residents upright all night also causes extreme fatigue and distress.
Extended exposure to moisture from urine and feces causes skin breakdown, urinary tract infections, and painful rashes. The acidic nature of these substances can cause chemical burns on sensitive skin within hours.
Post-procedure neglect after medical treatments like enemas is particularly dangerous, as residents may experience complications requiring immediate attention. Leaving someone in fecal matter for hours increases infection risk and causes severe discomfort.
Physical restraint without proper authorization can cause injuries, psychological trauma, and violates residents' fundamental rights. The blood found on the restrained resident's arm suggests the incident caused immediate physical harm.
Regulatory Framework Violations
The facility's investigation failures violate multiple aspects of federal nursing home regulations. The Centers for Medicare & Medicaid Services requires immediate reporting of suspected abuse to authorities and comprehensive internal investigations within 24 hours.
Proper investigations must include interviewing all relevant staff across shifts, reviewing care documentation, examining the resident's condition, and speaking with witnesses. The facility must then develop corrective action plans to prevent recurrence and monitor their effectiveness.
The inspection found that while grievance forms were completed, they lacked the depth and thoroughness required by regulation. Simple documentation of complaints without comprehensive fact-finding fails to meet federal standards for resident protection.
Facility Response and Acknowledgment
During interviews with federal inspectors, facility leadership acknowledged the inadequacy of their investigation processes. The nursing home administrator admitted that the incidents "should have been reported and investigated" properly, stating she had "learned the hard way to take ownership of abuse allegations."
The facility's social worker, who began working there in January 2025, reviewed the grievance forms during the inspection and agreed they represented "allegations of potential abuse" that warranted thorough investigation. She described her current practice of speaking with residents, floor staff, and previous shift workers when investigating complaints.
Resident Impact and Ongoing Concerns
Interviews with affected residents during the federal inspection revealed lasting emotional impacts from these incidents. One resident described feeling "terrible," "crying," and "overwhelmed and angry" about being left in soiled conditions all night. Another resident recalled being "tired and scared" after being left in her wheelchair without assistance.
These emotional responses highlight how investigation failures compound the original harm to residents. When facilities fail to properly address complaints, residents may lose confidence in the care system and become reluctant to report future problems, creating a cycle of unreported incidents.
The pattern of inadequate investigations also suggests potential staffing issues, training gaps, or systemic problems that remain unaddressed. Without proper investigation and corrective action, similar incidents are likely to continue occurring.
Industry Standards for Investigation
Best practices in nursing home administration require prompt, thorough responses to all care complaints. This includes immediate assessment of resident safety, comprehensive fact-finding involving all relevant parties, and development of specific corrective actions tailored to identified problems.
Effective investigation processes also include follow-up with residents to ensure satisfaction with resolutions and ongoing monitoring to verify that corrective actions prevent recurrence. The facility's grievance forms showed minimal follow-up and no evidence of systemic improvements.
The inspection findings underscore the critical importance of robust investigation procedures in maintaining resident safety and regulatory compliance. Federal inspectors will likely continue monitoring the facility's investigation practices to ensure adequate resident protection going forward.
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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