Edgerton Care Center, Inc
Edgerton Care Center, Inc in Edgerton, WI — inspection on March 31, 2025.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
On [DATE] at 8:54 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked what
this information and checking it off on a box. NHA A indicated when a resident comes into the facility, that day, medical records checks off that we have received everything and if we haven't, they reach out to the hospital.
Medical records checks the face sheets to make sure everything is there. NHA A indicated admissions is responsible for going in and asking the resident what they want for code status. If the resident wanted to be a DNR, admissions should have obtained the signed form from the hospital and if they didn't, then admissions should have coordinated with the doctor to get the state DNR form signed. NHA A indicated that the admission role is currently filled by a nurse.
Surveyor asked NHA A if the facility should have had the state DNR forms completed for residents on admission that wanted to be DNR. NHA A indicated, yes.
On [DATE] at 8:05 AM, NHA A (Nursing Home Administrator) provided a signed DHS (Department of Health Services) Emergency Care Do Not Resuscitate Order (DNR) form for R146 to surveyors that was dated [DATE] and signed by the physician and R146's Power of Attorney.
Surveyor asked NHA A if they had any documentation prior to [DATE] of a physician signed DNR form or order. NHA A indicated they did not.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
related to the hospital care, but she guesses that she could.
NHA A if she is aware of R28's grievance concerning not being able to sleep due to her roommate.
to do when they were told about R28's concern. NHA A indicates she would expect staff to inform her that R28 was raising these concerns. NHA A indicated she is aware of R6's concerns.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
she asked R46 do you feel safe now. NHA A stated, he said yes, now that you're here I feel safe.
situations, such as, if R46 gets combative ensure safety and reapproach. NHA A stated she notified
NHA A stated, police took photos and there is a visible thumb print on R46's arm that is referenced in the police report. NHA A clarified that CNA F was on R46's right side and LPN G was on R46's left side.
Surveyor asked NHA A, have any concerns been reported regarding CNA F or LPN G. NHA A stated, it may have been LPN G's first time at the facility and she thinks CNA F has worked here before.
Surveyor asked NHA A, what training has been provided to staff following this incident. NHA A stated, we did dementia education including reapproaching and notifying regarding abuse.
Surveyor asked NHA A, is it ever acceptable for staff to hold a resident's arms down. NHA A, stated, no, we are a restraint free building.
R46 was not free from physical abuse by CNA F and LPN G.
Cross Reference: F-F609, F-F610
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
Surveyors clarified with R146 which controller and he indicated the controller for the recliner.
supposed to have the remote for the recliner. LPN K indicated they don't want R146 to have it because he has been falling and he will put the recliner up and try to stand up. LPN K indicated today was the first time she put the remote on the floor so he couldn't use it and fall. LPN K indicated they have tried a low bed and fall mat, have offered to have him lie down, or go in the wheelchair but he refused. LPN K indicated, We have tried everything and this is what we're doing right now.
On 3/26/25 at 4:59 PM, Surveyors interviewed CNA L (Certified Nursing Assistant). CNA L indicated when she assists R146 to the recliner she will lay him out, elevate his legs, give him his call light, his table. CNA L indicated R146 really slides and this was the first time she took care of him and he was in the bed a lot so she said let's try the recliner. CNA L indicates as she was checking on him she noticed R146 sliding and so she was worried and put him back into bed.
Surveyors asked CNA L if R146 is able to use the recliner remote. CNA L indicated R146 did not try but that she had given it to him.
Surveyors asked CNA L if R146 is able to get out of his recliner alone. CNA L indicated R146 tries but isn't able to without going on the floor.
Surveyors asked CNA L if she feels R146 is strong enough to get out of the recliner alone. CNA L indicated on some days she thinks he could, but on other days, no.
On 3/31/25 at 9:01 AM Surveyors interviewed DON B (Director of Nursing) and asked if the facility completes an assessment to see if residents are safe to use power recliners. DON B indicated she believed therapy does an assessment.
Surveyors requested a copy of this assessment. (Of note, therapy notes provided did not include a recliner assessment.) Surveyor asked DON B if it is ok for staff to move the remote where the resident cannot reach it. DON B indicated, no.
Surveyors asked DON B if this could be considered a restraint. DON B indicated that it could be.
Surveyors asked DON B if R146 is able to get out of the recliner himself. DON B indicated R146 has been moving all over the place and that she doesn't know how safe it is.
Surveyor reviewed the interview with LPN K with DON B.
Surveyors asked if it could be considered a restraint if the remote for the recliner was purposefully put out of reach. DON B indicated it would be considered a restraint.
R146 was observed in an power lift recliner with the remote not in reach and thus restricting R146's movement.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
R3 has a BIMS of 11 out of 15, indicating R3 has a mild cognitive impairment.
(Certified Nursing Assistant) entered his room and waved his wet brief in his face.
The facility
On 3/31/25 at 4:24 PM, Surveyor interviewed NHA A about these grievance forms and these incidents.
Surveyor asked NHA to read the grievance forms and if they would be considered allegations of abuse. NHA A replied yes, they would be potential neglect allegations.
Surveyor asked NHA A if they were reports of potential abuse, had they been thoroughly investigated and reported.
NHA A replied that for most of them they followed through on them, but they didn't have a file or documentation on them. NHA A stated that they should have been reported and investigated. NHA A stated that she has learned the hard way to take ownership of abuse allegations and ensure that everything gets done properly.
The Facility treated these incidents for R18, R19, R6 and R3 as grievances instead of as abuse allegation; therefore, they did not follow their policy and did not report this accusation of abuse to the state agency.
Cross Reference F-F610.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
The facility failed to immediately report an allegation of abuse, protect their residents, and immediately educate CNA H and all staff regarding reporting and restraints (physically holding a resident's hands down.) Cross Reference: F-F600, F-F609
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
called to request the medication record to be faxed to [phone number] . RN stated patient is admitted
Cough, and Nausea .
On 1/27/25 at 11:50 AM, a Progress Note is written by RN BB that states, in part: Discharge
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
The facility failed to ensure that fall interventions were being followed for R2, thereby failing to keep R2 safe from repeated falls.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
malaise, foul odor, concentrated urine, blood in urine).
Start Date: 9/10/24.
R28's Physician Orders state, in part: Catheter care twice daily.
Special Instructions: catheter care twice daily.
Twice A Day. 06:30 - 14:30 (6:30 AM - 2:30 PM), 14:30 - 22:30 (2:30 PM - 10:30 PM).
Start Date: 9/3/24.
End Date: Open Ended.
Change drainage foley bag every 30 days.
Special Instructions: Change drainage foley bag every 30 days.
Once between the 3rd - 7th of the Month.
Start Date: 9/3/24.
End Date: Open Ended Check catheter securement device three times a day and change every Monday.
Special Instructions: Check catheter securement device three times a day and change every Monday.
Once a Day on Mon (Monday). 14:30 - 22:30.
Start Date: 9/3/24.
End Date: Open Ended.
Flush Foley catheter with 60ml (milliters) of sterile normal saline.
Special Instructions: to maintain patency. As Needed. PRN (As Needed) 1, PRN 2, PRN 3. (Indicates this can be done as needed up to 3 times a day).
Start Date: 10/3/24.
End Date: Open Ended.
Foley output Q (every) shift.
Every Shift. day (day shift), pm (evening shift), noc (night shift).
Start Date: 12/14/24.
End Date: Open Ended.
Historical orders: Change foley catheter 16 fr (French-indicates catheter size), 10 mL (milliters).
Once - One Time. 22:00 (10:00 PM).
Start Date: 3/11/25.
End Date: 3/11/25.
Change foley catheter as it is occluded.
Once - One Time. 17:30 (5:30 PM).
Start Date: 3/23/25.
End Date: 3/23/25. (Of note, this order specifically does not give a previous foley size or the size of the new foley to be place in the resident).
Of note: R28 has no active foley catheter order indicating the size of the catheter or how much to put into the catheter balloon.
On 3/31/24 at 11:41 AM, Surveyor interviewed DON (Director of Nursing) B.
Surveyor asked DON B what size foley catheter R28 is supposed to have. DON B reviewed R28's electronic medical record and indicated that she does not see the size in her care plan or in her physician orders.
Surveyor asked DON B if there should be an order for R28's foley catheter and it's size. DON B states, yes.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
enough! repeatedly. LPN S replied, I know I just want to get it all.
Surveyor asked LPN S about the leg
(pus-like fluid) drainage and macerated skin on the left lower extremity.
Surveyor also noted a large
surface of the wound) present in this wound. LPN S began the wound treatment on this leg by appearing to peel off skin.
Resident began yelling Ow! Ow! and wincing. LPN S replied I'm sorry, we got to get all the bad stuff off. R10 clenching teeth throughout process. LPN S instructed R10 to take a deep breath.
Resident continued to cry out and her breathing was shallow. LPN S continued the wound treatment as ordered. R10 continued to cry out please!. LPN S replied, I just need to clean it.
LPN S continued the wound treatment by applying the Santyl directly to the wound as ordered. R10 continued wincing and crying.
On 3/26/25 at 11:46 AM, Surveyor interviewed LPN S.
Surveyor asked LPN S when she premedicated R10. LPN S indicate she gave R10 morphine at about 9:57 AM.
Surveyor asked LPN S about LPN S mentioning R10 was more uncomfortable today. LPN S indicated she believed R10 had anxiety related to her phone call with her family prior to her wound care treatment.
Surveyor asked LPN S if she has ever stopped a wound treatment due to a resident being in pain or uncomfortable. LPN S indicates she has not, but slow, deep breaths usually work for R10.
Surveyor asked LPN S if she should have stopped R10's treatment due to her crying out in pain. LPN S indicates, yeah, maybe I should have stopped.
Surveyor asked LPN S if she has ever refused treatment due to pain. LPN S indicates R10 used to refuse due to pain but not so much anymore.
On 3/31/25 at 2:56 PM, Surveyor stopped by R10's room to interview her about her pain with wound treatments. At this time, R28, R10's roommate stopped Surveyor to let her know that R10 screams in pain during her dressing changes.
On 3/31/25 at 3:23 PM, Surveyor interviewed DON B and ADON HH.
Surveyor asked DON B if it is ordered, should staff premedicate residents prior to wound care. DON B indicates yes, unless the resident refuses.
Surveyor asked DON B if a resident is yelling out in pain and displaying visible signs of discomfort, what should the nurse do. DON B indicates the nurse should stop and reassess the pain.
Surveyor asked ADON HH if she usually participates in R10's wound care. ADON HH indicates she completes wound treatments with the wound Advanced Practice Nurse Prescriber.
Surveyor asked ADON HH what R10's usual demeanor is with wound treatments. ADON HH indicates R10 has good and bad days and that it usually depends on what is going on in her life, specifically family dynamics. ADON HH also indicates R10 has high anxiety days where very few interventions will be effective.
Surveyor asked ADON HH what interventions are effective on the high anxiety days. ADON HH indicates lorazepam generally works best on those days.
Surveyor advised ADON HH of the observations of pain made during wound treatment and asked what ADON HH would have done had she been completing the wound treatment. ADON HH indicated she would have stopped the treatment and evaluated R10's pain.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
The facility failed to ensure that each resident received food and drink that is palatable and at a safe and appetizing temperature.
525241 03/31/2025
Edgerton Care Center, Inc 313 Stoughton Rd.
Edgerton, WI 53534
indicated she felt if it was being cleaned at that frequency it would not have this much build up and
Surveyor observed the ice machine (located by the clean dish area) to have a white substance build
between maintenance cleanings and that this needed to be cleaned. DM E indicated there is not a log for when the ice machine should be cleaned.
On 3/27/25 at 2:22 PM Surveyors interviewed DM E and requested cleaning policies for the ovens and steam kettle. DM E indicated she had a cleaning schedule that indicates which person should be doing which cleaning.
Of note, cleaning logs that were provided did not list ovens or the steam kettle.
Example 4 On 3/24/25 at 12:20 PM, Surveyors observed clip boards on the 2nd floor refrigerator in the kitchenette nearest the elevators. A sign observed on the refrigerator indicates it is for resident items.
The March 2025 Fridge/Freezer temperature log has temperatures documented on March 1st and on March 18th - 23rd.
The February 2025 Fridge/Freezer log has temperatures documented for February 5th, 6th, and 10th.
On 3/24/25 at 1:51 PM, Surveyors interviewed CNA N who indicated she thought the refrigerator was only being used for things residents bring in, like soda.
Surveyors observed the inside of the refrigerator/freezer with CNA N. CNA N confirmed the fast food bag and an unopened bottle of soda noted in the refrigerator belong to residents. CNA N indicated the kitchen staff is responsible for monitoring and documenting temperatures of the fridge and freezer.
On 3/26/25 at 4:38 PM, Surveyors interviewed NHA A (Nursing Home Administrator) and reviewed the temperature logs referenced above. NHA A indicated she would expect the temperature log to be filled out completely for all dates.
On 3/27/25 at 2:22 PM Surveyor reviewed the temperature logs with DM E who indicated the temperatures should have been monitored by the kitchen staff and recorded.
The facility failed to immediately report an allegation of abuse, protect their residents, and immediately educate CNA H and all staff regarding reporting and restraints (physically holding a resident's hands down.)
Cross Reference:
The facility failed to accurately assess and monitor R6 for constipation, decreased fluid intake and output as well as changes in R6's mental status, resulting in frequent visits to the emergency department.
The facility failed to notify R6's primary care physician of his level of inadequate fluid intake and significant increases in urine output.
Between 1/1/25 and 3/31/25, R6 has been send to the hospital several times requiring IV (intravenous) fluid administration.
R16 experienced sudden onset of four (4) projectile coffee ground emesis (forceful vomiting of dark digested blood).
The facility waited 2+ hours to send R16 to the ED (emergency department).
R24 had a change of condition and focused assessments were not completed for continued monitoring of changes.
R2 had a changes in her physical condition that were not addressed by the facility as a change in condition.
This is evidenced by:
The facility policy entitled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, dated 9/2017, states, in part: . 1. As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms.
This should include a review of gastrointestinal problems during any recent hospitalization s . 2.
Examples of lower gastrointestinal tract conditions and symptoms include: . f. alteration in bowel movements; . h.
Residents taking antidiarrheal medications or medications related to bowel mobility . 3. In addition, the nurse shall assess and document/report the following: . c. change in mental status or level of consciousness; . e.
Signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status, dry mucous membranes, decreased urine output); f.
Abdominal assessment; .
Treatment/Management . 3.
The staff and physician will address significant complications due to bowel dysfunction .
Monitoring and Follow-Up . 2.
The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors. 3.
Before prescribing additional courses of medications, the physician should carefully evaluate and examine directly an individual who has not responded as expected to an initial course of treatment such as antidiarrheal medication, changes in the bowel regimen, etc.
525241
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525241 B.
Wing 03/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
During a NOC (night) shift on 11/28/24 to 11/29/24, CNA H (Certified Nursing Assistant) heard R46 calling for help. CNA H (Certified Nursing Assistant) observed R46 to be bright red and shaking with fresh blood on his right forearm (from a skin tear) and bedding. R46 stated, CNA F (Certified Nursing Assistant) and LPN G (Licensed Practical Nurse), both agency staff, wouldn't let him get up and held his hands down.
This allegation was not thoroughly investigated and the facility did not provide training to staff regarding physically restraining residents to ensure this does not occur again.
Evidenced by:
525241
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525241 B.
Wing 03/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.