Latest reports, citations, and penalties from CMS data
The January 2025 inspection also revealed that life-saving equipment was not maintained in working condition during a medical emergency....
The Licensed Vocational Nurse on duty confirmed the serious nature of the malfunction....
The facility's failure to maintain proper fall prevention protocols puts vulnerable residents at unnecessary risk....
EDGERTON, WI - Federal inspectors found that Edgerton Care Center, Inc....
On November 14, 2024, **Resident #2 experienced a severe choking episode while eating peanut butter crackers in the facility's communal living room**....
During the May inspection, surveyors documented that the resident's hair remained uncombed across multiple observations spanning two days....
The contamination was found in bathroom sinks throughout multiple units, shower facilities, and main hallway water sources....
The violations centered on staff's failure to properly assess conditions, implement physician orders, and monitor residents for complications....
However, the program lacked proper oversight mechanisms required by federal regulations....
A resident identified as R2 was admitted on October 9, 2024, with an assessment indicating they were at risk for developing pressure injuries....
## **Critical Wound Care Management Failures** Inspectors documented serious breakdowns in wound care protocols for a resident with multiple severe injuries....
However, critical communication breakdowns and procedural failures led to dangerous delays in processing these urgent tests....
Additionally, two CNAs who had been employed for years had not undergone required re-fingerprinting under the state's Rap Back system....
This resident had respiratory failure and required tracheostomy care, making proper oxygen delivery equipment essential for survival....
This administrative gap had cascading effects throughout the facility's operations....
## Critical Wound Care Documentation Failures The inspection revealed significant problems with wound care protocols that put residents at risk....
After completing care, the CNA restarted the machine to "running" status without involving licensed nursing staff....
## Medical and Safety Implications A functioning grievance process is essential for maintaining quality care in nursing facilities....
This successful resolution demonstrates the effectiveness of proper quality management systems in nursing home operations....
The Administrator acknowledged the facility's ongoing struggles with RN recruitment and retention during interviews with inspectors....