EDGERTON, WI - A comprehensive state inspection at Edgerton Care Center, Inc. has revealed significant failures in patient care that resulted in actual harm to residents and created widespread safety concerns throughout the 45-bed facility.
Severe Medical Neglect Leads to Repeated Emergency Hospitalizations
The most serious violation documented involves a resident with neurogenic bowel dysfunction and chronic constipation who required multiple emergency department visits due to inadequate medical monitoring. Between January and March 2025, this resident was hospitalized several times for dehydration requiring intravenous fluid administration.
Despite having a care plan requiring 64 ounces of fluid daily to maintain hydration, facility records show the resident never reached this goal during the three-month period. Documentation revealed no fluid intake recorded for 15 different days, with the highest single-day intake being only 1,360 milliliters - well below the prescribed 1,893 milliliters.
The facility's failure to properly monitor this resident's condition became critical when staff documented concerning symptoms without conducting proper assessments. On January 2nd, nursing notes described the resident as "lethargic and hard to arouse all morning" with no response to questions, yet no comprehensive evaluation was performed before transport to the emergency department.
Medical experts note that proper hydration monitoring is essential for residents with neurogenic bowel conditions, as dehydration can lead to serious complications including kidney dysfunction, electrolyte imbalances, and cardiovascular stress. The combination of multiple laxative medications that draw water from the body, coupled with inadequate fluid replacement, creates a dangerous cycle that can result in life-threatening dehydration.
Another resident experienced four episodes of projectile vomiting containing what appeared to be digested blood, yet facility staff waited over two hours before sending the individual to the emergency department. This delay in emergency response violated basic medical protocols that require immediate evaluation of any resident experiencing hematemesis.
Critical Breakdown in Emergency Response Protocols
The inspection revealed fundamental failures in nursing assessment and emergency response procedures. When residents exhibited clear signs of medical distress, including altered mental status and visible signs of dehydration, nurses failed to conduct comprehensive evaluations before determining appropriate interventions.
Current medical standards require immediate assessment when residents display symptoms such as lethargy, decreased responsiveness, or signs of dehydration including dry mucous membranes and decreased urine output. These symptoms can indicate serious underlying conditions requiring prompt medical intervention.
The Wisconsin Nurse Practice Act requires registered nurses to follow systematic assessment, planning, intervention, and evaluation processes. The inspection found that nurses consistently failed to complete thorough assessments before making critical decisions about resident care, particularly regarding emergency transport decisions.
Widespread Safety Hazards Compromise Resident Protection
Beyond individual medical care failures, inspectors identified systematic safety breakdowns affecting multiple residents. A resident with moderate cognitive impairment and smoking privileges was repeatedly found improperly disposing of cigarette materials and failing to return smoking equipment to staff despite facility policies requiring supervision.
Surveillance revealed this resident flicking ashes onto concrete surfaces, extinguishing cigarettes on furniture, and discarding butts in the facility driveway rather than using designated ashtrays. Staff progress notes documented multiple instances of having to retrieve smoking materials from the resident's room, indicating ongoing supervision failures.
Another resident with severe cognitive impairment experienced eight falls between January and March 2025 despite having multiple fall prevention interventions in place. These included specialized wheelchair features, non-slip socks, floor grip strips, and positioning aids. However, inspection observations revealed these safety measures were not consistently implemented.
Fall prevention in nursing homes requires systematic implementation of individualized interventions based on each resident's specific risk factors. When safety measures are inconsistently applied, residents remain at high risk for serious injuries including fractures, head trauma, and other complications that can significantly impact quality of life.
Inadequate Pain Management During Medical Procedures
Inspectors observed concerning pain management practices during wound care procedures. A resident receiving treatment for extensive lower extremity ulcers was observed crying out in distress and repeatedly asking staff to stop during dressing changes, despite receiving prescribed pain medication beforehand.
The facility's own pain management policy requires staff to recognize behavioral signs of pain including crying, grimacing, and resistance to care, and to modify approaches when residents display these symptoms. However, nursing staff continued painful procedures without reassessing pain levels or implementing additional comfort measures.
Effective pain management during wound care is crucial for healing and resident dignity. When residents experience inadequate pain control during medical procedures, it can lead to increased anxiety, delayed healing, and reluctance to accept necessary treatments. Proper pain assessment should include both pharmacological and non-pharmacological interventions.
Food Safety Violations Create Health Risks
The inspection identified multiple food service violations that could expose all 45 residents to foodborne illness. Kitchen staff were observed handling ready-to-eat foods with contaminated gloves after touching various surfaces without proper hand hygiene or glove changes.
Temperature monitoring failures included serving scrambled eggs at 115.3°F and sausage at 91.6°F - both below safe serving temperatures. Milk was served at 45.4°F, above the required maximum of 41°F. Kitchen equipment showed visible buildup and debris, including white substances on steam kettles and ice machines that had not been properly cleaned according to facility policies.
Food temperature control is critical in preventing foodborne illness, particularly in vulnerable populations like nursing home residents who may have compromised immune systems. Hot foods must be maintained at 165°F or above, while cold foods should be kept at 41°F or below to prevent bacterial growth.
Additional Issues Identified
The inspection also documented inadequate catheter management for a resident with an indwelling urinary catheter who lacked proper physician orders specifying catheter size and replacement schedules. This oversight could lead to improper catheter selection and increased infection risk.
Temperature monitoring of refrigerated resident foods was inconsistent, with documentation gaps spanning multiple days in February and March 2025. This failure to maintain proper food storage temperatures creates additional risks for foodborne illness.
The violations identified at Edgerton Care Center represent serious breakdowns in fundamental nursing home care standards that directly impacted resident health and safety. These findings highlight the critical importance of systematic monitoring, proper staff training, and consistent implementation of established care protocols to protect vulnerable nursing home residents.
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.
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