Edgerton Care Center: Resident Vomited Blood, Staff Waited - WI
Federal inspectors cited Edgerton Care Center for failing to provide appropriate treatment and care for four residents between January and March. The violations resulted in actual harm to two residents and potential harm to two others.
The resident who vomited blood, identified as R16, experienced "sudden onset of four projectile coffee ground emesis" — forceful vomiting of dark digested blood that indicates internal bleeding. Despite the severity of the symptoms, facility staff delayed emergency transport for over two hours.
Another resident suffered repeated hospitalizations for dehydration and constipation while staff failed to monitor his fluid intake and bowel movements. R6, who has neurogenic bowel and requires 64 ounces of fluid daily, never reached his intake goal during the three-month period inspectors reviewed. On 15 different days, staff documented no fluid intake at all.
Between January 1 and March 31, R6 was sent to the hospital multiple times requiring IV fluid administration. The most fluid he consumed in a single day was 1,360 milliliters — far below his prescribed 1,893 milliliters.
On January 6, R6 consumed no documented fluids and vomited what staff described as "liquid brown in color with some small amounts of brown colored sediment that was highly suspicious of stool." A nurse noted the resident "stated he drank very little for fluids" but no abdominal assessment was conducted before transport.
The pattern continued through January. On January 20, R6's fluid intake wasn't recorded while his urine output was 950 milliliters. The next day, with no recorded intake and 1,600 milliliters of urine output, staff noted he was "lethargic" and "unable to stay awake."
A nurse wrote that R6 had been "vomiting for 2-3 days" and "has not held anything down today" but inspection records show only one prior vomiting episode documented. No abdominal assessments were conducted during this period.
On January 22, with only 30 milliliters of fluid intake documented against 900 milliliters of urine output, R6 became "minimally responsive to verbal commands." Staff noted his mouth was "so dry upon return that he was unable to suck on a straw."
The facility's own policy requires nurses to assess for signs of dehydration including "altered level of consciousness, lethargy, dizziness, recent change in mental status, dry mucous membranes, decreased urine output." Staff documented these exact symptoms but failed to conduct proper assessments.
R6's care plan acknowledged his "potential for dehydration" related to "frequent episodes of nausea/vomiting, recurrent UTIs, periods of lethargy with refusals of meals/fluids." Despite multiple hospitalizations, no additional interventions were implemented to improve his fluid intake.
The facility also failed to follow fall prevention measures for R2, a resident with severe cognitive impairment who fell eight times between January 6 and March 13. Her care plan specified numerous interventions including gripper socks, Dycem in her wheelchair, gripper strips on the floor, and shoes kept at bedside.
When inspectors observed R2 at breakfast, she wore regular socks instead of gripper socks and no shoes. Later, they found her wheelchair without Dycem, no gripper strips by her bed, no shoes in the wheelchair, and no floor mat — all required interventions that weren't in place.
Staff knew the interventions weren't being followed. The Director of Nursing told inspectors she expected care plan interventions to be implemented but admitted the Assistant Director of Nursing, who was new, "probably was not aware that she should be monitoring this."
Additional violations included a resident keeping partial cigarettes in his room despite facility smoking policies, improper pain management during wound care, and food safety issues. Staff served cold eggs and sausage to residents, with breakfast items measuring 115 degrees and 91 degrees respectively — well below safe serving temperatures.
Kitchen staff were observed touching multiple surfaces while wearing the same gloves used to handle ready-to-eat foods. Equipment including ovens and steam kettles showed visible buildup and debris, indicating inadequate cleaning.
The inspection was conducted March 31 following a complaint. The facility's administrator and Director of Nursing acknowledged the violations during interviews with inspectors.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 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 for failing to provide appropriate treatment and care for four residents between January and March.
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.