Edgerton Care Center: Recliner Remote Used as Restraint - WI
The resident, identified in inspection records as R146, was a fall risk. When surveyors arrived on March 25, 2025, they found him sitting in a power lift recliner with the remote on the floor behind the right side of the chair, positioned where he could not get to it.
LPN K, a licensed practical nurse, told surveyors that morning that staff had deliberately kept the remote away from R146 because he would raise the chair and attempt to stand, creating a fall risk. She said the facility had tried other approaches, including a low bed, a fall mat, and offering him a wheelchair, but R146 had refused all of them. "We have tried everything and this is what we're doing right now," she told surveyors. She said that day was the first time she had put the remote on the floor.
A certified nursing assistant, CNA L, gave surveyors a different account the following afternoon. She said she had given R146 the remote when she seated him in the recliner. She also said R146 hadn't tried to use it. When surveyors asked whether R146 could get out of the recliner on his own, she said he tries but can't do it without ending up on the floor. Asked whether she thought he was strong enough to get out alone, she said it depended on the day.
The two accounts, taken a day apart, left the basic facts of who controlled the remote, and when, unresolved.
When surveyors brought the issue to Director of Nursing B on March 31, the conversation turned direct. DON B said she believed therapy had completed an assessment to determine whether R146 could safely use a power recliner. Surveyors asked for a copy. The therapy notes provided contained no recliner assessment.
Surveyors then asked DON B whether it was acceptable for staff to move the remote out of a resident's reach. She said no. They asked whether doing so could be considered a restraint. She said it could. They walked her through what LPN K had described, then asked again: if the remote was purposefully placed where the resident couldn't reach it, would that be a restraint? DON B said it would.
She also told surveyors she wasn't sure how safe R146's situation was, noting he had "been moving all over the place."
The inspection report cited the deficiency at a level of minimal harm or potential for actual harm, affecting few residents.
What the record shows is a staff member improvising a solution to a genuine problem, a resident who falls, who refuses alternatives, who cannot reliably get himself out of a chair safely, and a nurse who decided that hiding the remote was the answer. It also shows a facility that had no documented assessment confirming whether R146 should have been using a power recliner at all, and a director of nursing who, when pressed, agreed that what her staff had done met the definition of a restraint.
R146 remained in the recliner, the remote on the floor behind him, able to call for help but not to move the chair himself.
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 30, 2026 · Our methodology
Edgerton Care Center, Inc in Edgerton, WI was cited for violations during a health inspection on March 31, 2025.
The resident, identified in inspection records as R146, was a fall risk.
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.