Edgerton, WI
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
313 Stoughton Rd, Edgerton, WI
(608) 884-1330
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
61
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wisconsin Illinois Senior Housing, Inc.
Operator or chain grouping
Approved since
1971-05-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.82
Registered nurse staffing
LPN hours / resident day
1.07
Licensed practical nurse staffing
Aide hours / resident day
3.41
Nurse aide staffing
Weekend hours
4.58
Weekend nurse staffing
RN turnover
59%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.7 |
1.6
2.1 pts worse
|
1.9
1.8 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.2
1 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
95.7%
1.7 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.0%
2.8 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.2%
About the same
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.3% |
4.9%
1.6 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
16.6%
2 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
16.7%
0.1 pts worse
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.6% |
21.1%
3.5 pts better
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
17.3%
8.8 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
3.0%
0.4 pts better
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
25.5%
3.9 pts better
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.5%
2.2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.2% |
86.8%
0.6 pts worse
|
81.7%
4.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.0% |
15.0%
14 pts worse
|
12.0%
17 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
82.2%
12.6 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
22.7%
2.6 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-04-24
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-04-24
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-08
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-24
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-24
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-04-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-24
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-17
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-17
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-17
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-17
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-05-17
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-17
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-25
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-17
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-05-17
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-09-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-17
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-17
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-28
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-17
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-13
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-28
Inspection history
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-24
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-24
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-24
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-24
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-24
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-24
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-24
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-24
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-24
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-24
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-07
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-22
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-22
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-22
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-22
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-22
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-01
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-01
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-03-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-01
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-03-01
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-01
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-23
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-01
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-03-01
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-01
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-01
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-03-01
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-01
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-01
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-01
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-03-01
Penalties and ownership
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
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