Edgerton Care Center: Wound Care Pain Ignored - WI
A federal inspector watched the entire thing.
The resident, identified in inspection records only as R10, had open wounds on both lower legs. The right leg wound had started as a fluid-filled blister below her knee and worsened over time, soaked through by her dressings until the surrounding skin broke down. The left leg was worse: a large wound on the back of the leg, filled with slough, the dead tissue that accumulates at a wound's surface.
The nurse, identified as LPN S, had given R10 morphine at approximately 9:57 a.m. before beginning the wound treatment. By the time she started peeling tissue from the left leg, nearly two hours had passed.
The inspector watched LPN S begin what appeared to be debridement, peeling skin from the wound. R10 immediately cried out. "Ow! Ow!" LPN S told her, "I'm sorry, we got to get all the bad stuff off." R10 clenched her teeth. LPN S told her to take a deep breath. R10's breathing went shallow. She kept crying out. LPN S kept working.
At some point earlier in the treatment, R10 had apparently told the nurse it was enough. The inspector's notes capture LPN S responding: "I know, I just want to get it all."
When LPN S moved to applying Santyl, a prescription ointment used to dissolve dead wound tissue, directly to the wound, R10 was still wincing and crying. She cried out, "Please!" LPN S told her, "I just need to clean it."
The inspector interviewed LPN S shortly after. Asked whether she had ever stopped a wound treatment because a resident was in pain, LPN S said she had not. Deep breaths, she said, usually worked for R10. Asked directly whether she should have stopped given what had just happened, LPN S said, "Yeah, maybe I should have stopped."
She also told the inspector that R10 used to refuse wound treatments because of pain. Not so much anymore.
R10's roommate, identified as R28, stopped the inspector in the hallway five days later, on March 31, to say that R10 screams during her dressing changes.
The facility's own leadership described a different standard of care than what the inspector had observed. The Director of Nursing, identified as DON B, told the inspector that if a resident is yelling and showing visible signs of discomfort, the nurse should stop and reassess the pain. The Assistant Director of Nursing, identified as ADON HH, said she would have stopped the treatment and evaluated R10's pain.
ADON HH also described R10 as having high-anxiety days when very few interventions are effective, and said lorazepam generally works best on those days. She attributed R10's distress partly to family dynamics, saying R10 had spoken with family by phone before the wound care that morning.
LPN S offered the same explanation. She believed R10's pain response was related to anxiety from that phone call.
The inspector's account does not describe any attempt to evaluate whether the morphine given nearly two hours earlier had worn off, whether a different pain medication was available, or whether the treatment should have been paused and rescheduled.
R10's wounds, the inspector noted, included purulent drainage, the pus-like fluid that signals infection or breakdown, alongside the macerated skin that had developed from fluid-soaked dressings. The wound on the back of her left leg, the one that prompted the screaming, had slough throughout.
The inspection was completed March 31, 2025. CMS rated the violation as causing minimal harm or potential for actual harm, affecting a limited number of residents.
R10's roommate had been listening to the screaming from the other side of their shared room.
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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Last verified: October 31, 2026 · Our methodology
Edgerton Care Center, Inc in Edgerton, WI was cited for violations during a health inspection on March 31, 2025.
A federal inspector watched the entire thing.
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.