Edgerton Care Center, Inc

In the surveyor’s words

From the most serious findings on record at Edgerton Care Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, patternF678May 14, 2026

  Based on interview and record review, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 1 Residents reviewed (R6) this has the potential to affect 25 full code residents that reside in the facility. R6 indicated he wished his code status to be full code. R6 was found to be pulseless and not breathing. Facility staff failed to utilize life-support equipment while providing CPR on R6. […]

• Immediate jeopardy, isolatedF600Jan 25, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident (R291) did not abuse 2 out of 18 sampled Residents (R290 and R33.) R291 has a history of exhibiting socially inappropriate/disruptive behavior towards staff and other residents. The facility was aware of R291's behavior and this behavior was noted in R291's care plan. R291's care plan indicates R291 is one on one supervision while resident awake, door alarm, and 15-minute checks while resident is sleeping. Despite knowing these behaviors, the facility did not ensure R291 had adequate supervision which led to R291 entering R290's room, physically grabbing R290's head while R290 was in bed, and screaming and swearing at R290 to Get the fuck out of my bed. […]

• Immediate jeopardy, isolatedF689Jan 25, 2023

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to ensure safety and prevent accidents for 1 of 2 residents (R291) reviewed for wandering and resident to resident altercations, and residents' environment is free of accident hazards for 3 of 3 sampled residents (R34, R8, and R28) reviewed for falls, 2 of 2 units with unsecured chemicals, and 2 of 2 residents (R5 and R7) with medication left at bedside. Example 1 R291 is at high risk for wandering and has a known history of aggressive behaviors toward other residents and staff. The facility failed to implement appropriate interventions, failed to follow resident care plans, and failed to put adequate supervision in place. […]

• Immediate jeopardy, isolatedF600Oct 31, 2022

  Based on observation, interview and record review the facility failed to ensure a resident (R2) did not abuse 3 out of 6 sampled Residents (R6, R1, and R3). R2 has a history of making inappropriate sexual statements toward staff, trying to grab and touch staff's breasts or other private areas. The facility was aware of R2's behavior and care planned this behavior. Despite knowing these behaviors, the facility did not ensure R2 had adequate supervision which led to R2 sexually touching a female resident. R2 also entered other residents' rooms uninvited and struck or frightened them. The facility's failure to ensure adequate supervision to prevent abuse created a finding of immediate jeopardy that began on 9/8/22. […]

• Immediate jeopardy, isolatedF686Sep 27, 2022

  Based on observation, interview and record review the facility did not ensure that residents receive care consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries for 3 of 6 sampled residents (R) (R1, R4 and R6). R1 was at risk for pressure injury. The facility failed to ensure the pressure injury was assessed and measured weekly. R1's pressure injury deteriorated to a stage IV pressure injury which became infected. The facility's failure to ensure residents at risk for pressure injuries receive the care and services to prevent pressure injury deterioration created a finding of immediate jeopardy that began on 7/12/22. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 9/15/22 at 3:45 PM. […]