Edgerton Care Center: Fall Safety Failures - WI
Federal inspectors cited Edgerton Care Center, Inc., a nursing home at 313 Stoughton Road, following a March 31, 2025 inspection. The deficiency centered on a single resident, identified in inspection records as R2, whose care plan included specific interventions to reduce her risk of falling. Inspectors found those interventions were not being followed.
The non-slip mat, called a Dycem, was designed to keep R2 stable in her wheelchair. The gripper socks were meant to reduce the chance of slipping when she was on her feet. Together, they were part of a documented plan to keep her safe. Neither was being consistently used.
The facility's own administrator acknowledged it.
When inspectors raised the issue, the nursing home administrator, identified in the report as NHA A, confirmed that yes, she would expect care-planned interventions to be followed. Then she explained why they weren't. R2, she said, removes the Dycem from her wheelchair and hides it in the drawer. R2 is constantly taking off her gripper socks. The administrator said staff had tried many interventions and that they were doing their best to keep her safe.
That explanation did not satisfy inspectors.
The inspection report concluded plainly: the facility failed to ensure that fall interventions were being followed for R2, thereby failing to keep her safe from repeated falls. The word "repeated" is doing real work in that sentence. R2 had not fallen once. She had fallen more than once. The care plan existed because the falls had already happened.
The level of harm was classified as minimal harm or potential for actual harm, meaning inspectors did not document a serious injury resulting directly from the lapse. The deficiency was noted as affecting a small number of residents. But the classification of "minimal harm" in federal inspection language does not mean nothing happened. It means the documented harm at the time of inspection had not yet risen to the level of serious injury. A resident who falls repeatedly in a nursing home, without her fall prevention plan being followed, is a resident at ongoing risk.
What the administrator's response revealed is a gap that nursing home operators and regulators have long struggled to close: the distance between a care plan written on paper and care actually delivered in the hallway, in the room, at the wheelchair. A Dycem mat and a pair of gripper socks are not sophisticated medical technology. They are simple tools. The problem was not that the tools failed. The problem was that no one made sure they stayed in place, or found a way to address the fact that R2 kept removing them.
If a resident is documented as removing her own fall prevention equipment, that behavior itself becomes part of the clinical picture. It is something to be addressed, monitored, and recorded, not simply noted in passing as an explanation for why the care plan was not followed.
The administrator's comment that staff had tried "lots of interventions" with R2 and were trying to keep her safe may be true. It does not appear in the inspection record as documented evidence of those attempts, only as a verbal statement offered to inspectors after the deficiency was identified.
Edgerton Care Center has 50 certified beds according to federal records. The inspection was completed March 31, 2025.
R2's care plan was written because she had already fallen. The mat went into the drawer. The socks came off. And the falls kept coming.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 30, 2026 · Our methodology
Edgerton Care Center, Inc in Edgerton, WI was cited for violations during a health inspection on March 31, 2025.
Federal inspectors cited Edgerton Care Center, Inc., a nursing home at 313 Stoughton Road, following a March 31, 2025 inspection.
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.