Edgerton Care Center: Staff Held Resident Down - WI
The incident at Edgerton Care Center, a skilled nursing facility at 313 Stoughton Road, was among the deficiencies cited by federal inspectors who completed a survey on March 31, 2025. The finding that the resident was not free from physical abuse was cross-referenced to violations covering abuse reporting and investigation requirements.
The resident, identified in inspection records as Resident 46, had dementia. A certified nursing assistant identified as CNA F was positioned on his right side. A licensed practical nurse identified as LPN G was on his left. Together, they held his arms down.
The facility's nursing home administrator, identified in the report as NHA A, told the surveyor it may have been LPN G's first time working at the facility. She believed CNA F had worked there before. Both were agency staff, meaning they were not direct employees of Edgerton Care Center but were placed there through a staffing agency.
Neither will be coming back.
NHA A told the surveyor she had notified the agency and that both workers were banned not only from Edgerton Care Center but from any of the agency's sister facilities as well. She said police responded, documented the incident, and photographed Resident 46's arm. The thumbprint is referenced in the police report.
When the surveyor asked whether the administrator had observed any lasting effects on the resident, NHA A said no. No changes in his daily routine. No changes in his mood. She described care plans already in place to address situations where he becomes combative, including instructions to ensure safety and reapproach rather than restrain.
The surveyor asked directly: is it ever acceptable for staff to hold a resident's arms down?
NHA A said no. "We are a restraint-free building," she told the surveyor.
The surveyor also asked NHA A whether any prior concerns had been reported about either CNA F or LPN G before this incident. The administrator did not indicate that any had been.
After the incident, the facility conducted dementia education for staff, covering reapproaching techniques and abuse reporting obligations, according to NHA A.
The surveyor asked Resident 46 directly whether he felt safe. He said yes, now that she was there, he felt safe.
That answer, offered by a man with dementia to a federal inspector who had just arrived at his facility, was part of the record inspectors used to document what happened to him. He felt safe with the surveyor present. The inspection report does not say what he felt on the day two people held his arms down and left a mark that police later photographed as evidence.
The deficiency was cited at a level of minimal harm, affecting few residents. The citation noted that Resident 46 was not free from physical abuse by CNA F and LPN G.
Edgerton Care Center is a small facility in Rock County, roughly midway between Madison and Janesville. The inspection report does not describe what prompted the two workers to hold Resident 46 down, only that they did, that a bruise resulted, and that the bruise was visible enough to photograph.
Physical restraint of nursing home residents, including holding limbs down, is classified as physical abuse under federal standards when it is not a prescribed medical intervention performed according to a care plan. Edgerton Care Center's own administrator confirmed the facility does not restrain residents and that what happened to Resident 46 fell outside anything the facility would sanction.
The use of agency staff in nursing homes has drawn scrutiny nationally as facilities have leaned more heavily on temporary workers to fill chronic staffing gaps. Agency workers may be unfamiliar with individual residents, their diagnoses, their behavioral histories, and the specific approaches a facility uses to manage moments of agitation or distress in residents with dementia. NHA A's acknowledgment that LPN G may have been working at the facility for the first time the night this happened sits in the record without further explanation.
The care plan for Resident 46 already anticipated that he could become combative. It told staff to ensure safety and reapproach. That instruction existed before the incident. Whether either agency worker was aware of it, or had been given access to it, the inspection report does not say.
What the report does say is that a thumbprint remained on his arm after they were done.
Police documented it. The surveyor documented it. The administrator confirmed it. And when asked whether she saw any long-term effects on Resident 46, NHA A said no changes were noted in his daily routine or mood.
The surveyor's question about whether Resident 46 felt safe came after all of that, during a conversation the inspection report captures in a single exchange. He said yes, now that she was there.
The two workers who held him down were gone by then.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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 finding that the resident was not free from physical abuse was cross-referenced to violations covering abuse reporting and investigation requirements.
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.