Edgerton Care Center: Resident Restrained, Abuse Unreported - WI
That is what inspectors found at Edgerton Care Center, a nursing facility at 313 Stoughton Road, when they completed their survey on March 31, 2025. The inspection identified failures in abuse reporting, resident protection, and staff education that the facility's own administrator acknowledged should have been handled differently at every step.
The resident at the center of the incident is identified in inspection records only as R46. What inspectors documented is this: a certified nursing assistant, identified as CNA F, physically restrained R46 by holding the resident's hands down. Another nursing assistant, CNA H, was the only other staff member working on the third floor at the time, alongside a licensed practical nurse identified as LPN G.
CNA H knew what had happened. CNA H did not immediately report it up the chain of command in a way that reached the nursing home administrator, identified in records as NHA A. The administrator told inspectors directly that if CNA H had reached her, she would have told CNA F and LPN G that R46 should have left the facility immediately.
That call never came.
The next shift arrived. Someone noticed bruising on R46. That is how it surfaced.
When the surveyor asked NHA A to walk through what happened, the administrator described exactly that sequence: first shift came in and noticed R46 had bruising. The physical restraint, the hands held down, was discovered not because anyone on the third floor that night reported it, but because it left a mark.
The administrator did not attempt to minimize what CNA F had done. Asked directly whether physically holding a resident's hands down constituted a restraint, NHA A did not dispute it. The record reflects no argument about definitions, no suggestion that what occurred was routine or justified. What NHA A told inspectors was simpler and, in some ways, more troubling: after the incident, the facility had not educated CNA H or any other staff member about reporting obligations or about the prohibition on physically restraining residents.
The surveyor asked NHA A directly: did you educate staff regarding restraining residents? No, NHA A said. Should you have? Yes.
That exchange, documented in the federal inspection record, captures the central failure inspectors cited. It was not only that CNA F held a resident's hands down. It was that afterward, the people who witnessed it or worked alongside it were never told, formally or otherwise, that this was abuse, that it required immediate reporting, and that it could not happen again. The third floor kept working. The staff kept working. Nobody sat them down.
Inspectors cited the facility for three interlocking failures. The facility failed to immediately report an allegation of abuse. It failed to protect its residents. And it failed to immediately educate CNA H and all staff about reporting requirements and about physical restraints.
The deficiency was cross-referenced to F600 and F609, the federal regulatory tags governing abuse prohibition and the reporting of alleged violations. The level of harm was assessed as minimal harm or potential for actual harm, and the violation was noted as affecting some residents, not just R46.
That last detail matters. When inspectors note that a violation affects "some residents," they are not describing a one-time lapse that touched one person and resolved itself. They are describing a systemic condition. In this case, the systemic condition was a third-floor staff culture in which a nursing assistant physically held a resident down, a second nursing assistant witnessed or became aware of it, a licensed nurse was present, and none of them escalated it in a way that reached the administrator before the next shift found bruises.
NHA A acknowledged the facility's responsibility plainly. The surveyor asked whether the facility was responsible for protecting R46 as well as all other residents. Yes, NHA A said. There was no hedging in that answer, and there was no apparent dispute about whether what CNA F did was wrong. The administrator agreed it was wrong. The administrator agreed staff should have been educated. The administrator agreed CNA H should have reported directly to her.
What the administrator could not explain away was the gap between what should have happened and what did.
Physical restraint of a nursing home resident, including holding a person's hands down, is not a gray area in long-term care. Residents in nursing facilities have the right to be free from restraints used for discipline or convenience, and the use of physical force to hold a resident's limbs constitutes a restraint regardless of how briefly it occurs or what prompted it. The fact that NHA A did not dispute this when asked suggests the facility understood the line that had been crossed. The failure was not in recognizing the violation after the fact. The failure was in what happened in the hours and days that followed, when the people who could have acted did not.
CNA H was, by the administrator's own account, the only other staff member on the third floor that night besides CNA F and LPN G. That is a small team working a single floor of a nursing facility. Everyone on that floor knew, or had reason to know, what had occurred. The inspection record does not describe CNA H as having concealed what happened or lied about it. It describes CNA H as having failed to reach NHA A directly. Whether that reflects a training failure, a reporting culture failure, or something else, the inspection record does not say. What it says is that the administrator acknowledged no education had been provided to CNA H or to staff more broadly, before or after the incident.
R46's bruising was found by the shift that came in after. That image, a resident discovered bruised by workers arriving to relieve the crew that had been there when it happened, is the practical consequence of a facility where the reporting chain broke down entirely. The resident did not report it. No staff member on the floor reported it in time. The bruising reported it.
Edgerton Care Center had 57 days between the inspection completion date of March 31, 2025, and the date this report was printed. The inspection record notes that for information on the facility's plan to correct this deficiency, readers should contact the nursing home or the state survey agency directly.
What the record does not contain is any indication of what R46's condition was after the bruising was found, whether the resident remained at the facility, or what consequences, if any, CNA F faced. The administrator said CNA F should have left the facility immediately. Whether that happened is not documented in the inspection findings.
R46 was bruised. Someone held that resident's hands down. And the people on the floor that night went home without making a call.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 31, 2026 · Our methodology
Edgerton Care Center, Inc in Edgerton, WI was cited for abuse-related violations during a health inspection on March 31, 2025.
That is what inspectors found at Edgerton Care Center, a nursing facility at 313 Stoughton Road, when they completed their survey on March 31, 2025.
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.