Edgerton Care Center: Missing DNR Order Found - WI
The inspection, completed March 31, 2025, found that the facility had no physician-signed DNR order on file for a resident identified in records as R146, despite that resident having chosen a DNR status. The signed Department of Health Services Emergency Care Do Not Resuscitate Order that the nursing home administrator, identified in the report as NHA A, handed over to surveyors was dated the same day it was provided. The physician and R146's Power of Attorney had both signed it. When the surveyor asked whether any documentation existed prior to that date, NHA A said they did not have any.
The gap matters. A DNR order directs emergency responders and facility staff not to perform resuscitation if a resident's heart stops or they stop breathing. Without a signed physician order in the chart, that instruction has no legal or medical standing. A resident who chose not to be resuscitated could, in the absence of proper paperwork, receive exactly the intervention they said they did not want.
NHA A described the facility's intake process to surveyors in some detail. Admissions staff, currently a nurse, are responsible for asking residents their code status on the day they arrive. If a resident wants a DNR, admissions should either obtain the signed form from the transferring hospital or coordinate with the physician to get the state form completed. Medical records staff are supposed to check the face sheet on admission day to confirm all required documents have been received, and to follow up with the hospital if anything is missing.
The surveyor asked NHA A directly: should the facility have had the state DNR forms completed for residents on admission who wanted DNR status? NHA A said yes.
That answer made the missing paperwork harder to explain, not easier. The administrator had just described a system with multiple checkpoints, admissions staff asking the question, medical records verifying the response, a follow-up process for anything missing. R146's form wasn't missing from a hospital that failed to send it. It didn't exist at all until a surveyor came looking.
The inspection report classified the deficiency as minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's language, not a finding that nothing could have gone wrong. It means inspectors did not document that R146 was actually subjected to unwanted resuscitation. It does not mean the risk was theoretical. A cardiac event, a fall, a sudden medical crisis, and the absence of that signed order could have put staff in the position of making a decision that wasn't theirs to make.
Edgerton Care Center sits on Stoughton Road in Edgerton, a small city in Rock County. The facility's provider identification number is 525241.
What the inspection does not resolve is how long R146 had been a resident without proper documentation, or whether other residents with DNR wishes had similar gaps in their charts. The report addresses one resident and one missing form. NHA A's description of the admissions process as a multi-step verification system raises the question of where, exactly, R146's paperwork fell through, and whether the answer to the surveyor's question the morning of March 31 was the first time anyone at the facility had thought to ask it.
R146 has a signed order now. It was dated the morning a surveyor asked for it.
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 29, 2026 · Our methodology
Edgerton Care Center, Inc in Edgerton, WI was cited for violations during a health inspection on March 31, 2025.
The physician and R146's Power of Attorney had both signed 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.