Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edgebrook Care Center during CMS and state inspections, most recent first.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate direct care staffing data to CMS for a quarter reviewed. PBJ review showed excessively low weekend staffing had triggered, and the nursing schedule showed most weekends had 7 NAs and 1 licensed nurse on both the morning and afternoon shifts. On six weekends, NA staffing fell below 7, although an additional licensed nurse was scheduled. The administrator stated an LPN was sometimes assigned to work the floor as a NA due to call-ins or no available staff, and that the LPN time was coded in PBJ as an LPN rather than as a NA.
Infection Control Program and PPE Use Deficiencies: The facility failed to maintain an infection control program with complete surveillance and tracking of resident infections and staff illnesses. Resident logs lacked medication details, antibiotic time-out documentation, and enhanced barrier precaution information, while staff illness logs did not show symptom resolution or return-to-work dates. During an insulin administration observation, an LPN prepared and gave Lispro insulin to a resident without wearing gloves, and the DON stated gloves were expected for tasks with potential blood or body fluid exposure.
The infection preventionist failed to provide adequate oversight of the infection control program. Resident infection surveillance logs lacked maps of infection locations, did not identify residents on enhanced barrier precautions, and were incomplete regarding antibiotic details and antibiotic time outs. Staff illness logs for GI and respiratory symptoms also lacked documentation of symptom resolution, last day worked, and return-to-work dates. The IP acknowledged the missing information, stated staff sometimes returned to work the next day, and agreed she had not ensured thorough surveillance documentation or oversight of the program.
Failure to Assess and Document Right Wrist Splint: A resident admitted with a glove and wrist splint on the right wrist was not accurately assessed or documented. The MDS, care plan, physician orders, MAR, TAR, and admit/re-admit data collection form did not include the splint or any right hand/wrist mobility restriction, and an RN stated she was unaware the resident had the device. The resident reported she had worn the splint for a long time because of a prior bone infection and that staff had not asked about it.
Inaccurate Documentation and Unclear Treatment Order for Lymphedema Boots: A resident with Alzheimer's disease, impaired cognition, and chronic venous disease had orders for recliner positioning, leg elevation, and lymphedema pumps. Staff documented the treatment as administered on the TAR even when the resident was observed without the boots on, and interviews showed an LPN sometimes charted before attempting the treatment and another LPN charted the recliner order as completed when it had only been offered. The DON acknowledged the documentation was misleading and that staff were not charting after the task was completed.
Failure to monitor antibiotic use and complete antibiotic time outs for 2 residents. One resident with impaired cognition, HF, DM, and dementia received cephalexin for a UTI, and another resident with severe cognitive impairment, dementia, and Parkinson’s disease received cefdinir for a URI. The infection log showed antibiotics were prescribed, but there was no documentation that the required 48-72 hour antibiotic time out was completed or sent to the MD for review.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents as required.
The facility failed to maintain adequate staffing levels on weekends, as required by their resident census and care levels. During a review period, it was found that the facility did not meet the necessary staffing numbers for several weekend evening shifts, resulting in a deficiency. Despite using a program to notify staff of open shifts and attempting to fill these shifts with contract staff or by mandating extended hours, the facility's efforts were insufficient to meet the required staffing levels.
The facility failed to reconcile controlled substances stored in a refrigerator as part of their emergency kit. An unlocked refrigerator contained controlled substances, and staff, including an RN, TMA, and LPN, confirmed that narcotics were not being counted or locks verified since a pharmacy change. The director of nursing acknowledged the lapse, which was against the facility's policy requiring daily reconciliation and secure storage.
A resident with severe cognitive impairment was transferred to the hospital without the facility notifying the family in writing about the bed hold policy and potential costs. Although the family was informed of the hospital transfer, the bed hold policy was not discussed or provided, contrary to the facility's policy requiring notification within 24 hours.
The facility did not follow CDC recommendations for enhanced barrier precautions (EBP) for two residents with indwelling devices or MDRO. Staff inconsistently used gowns and gloves during high-contact care activities, despite care plans and signage indicating the need for such precautions. The director of nursing was unaware of the full scope of EBP requirements.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Quarter 3 of 2025 based on payroll and other verifiable and auditable data. Review of the PBJ Report 1705D identified excessively low weekend staffing had triggered, and review of the nursing schedule from April 1 through June 30, 2025 showed that most weekends had 7 nursing assistants and 1 licensed nurse scheduled for both the morning and afternoon shifts. Six weekends were identified where staffing fell below 7 nursing assistants, although an additional licensed nurse was scheduled. During interview, the administrator stated that on weekends with lower nursing assistant staffing due to call-ins or no available staff, the facility had scheduled an LPN to work the floor as a nursing assistant. She confirmed that the LPN time was coded in PBJ as a licensed nurse rather than as a nursing assistant, consistent with PBJ guidance for a change in the LPN's normal role. A policy on coding the PBJ report was requested but not provided by the end of survey.
Infection Control Program and PPE Use Deficiencies
Penalty
Summary
The facility failed to implement and maintain an infection control program that included thorough data collection, analysis of facility infections, and tracking and trending to reduce the spread of infections within the facility. Review of the monthly infection surveillance and staff call-in logs from August through October 2025 showed missing information in the resident infection surveillance, including no documentation of medications prescribed, no antibiotic time out, and no inclusion of residents on enhanced barrier precautions. The resident infection logs also identified residents as being on standard precautions only, with no other precaution type documented. The facility’s surveillance policy dated 11/10/25 lacked guidance on what should be included in the infection surveillance log, when a resident should be placed on precautions, what type of precaution should be implemented, and provided no guidance on staff illness surveillance. The staff illness logs for the same period documented multiple staff call-ins for nausea and vomiting, diarrhea and fever, upper respiratory symptoms and fever, GI symptoms, respiratory symptoms, and other symptoms, but did not identify when symptoms resolved, the last day worked, or when staff returned to work. The infection preventionist stated several staff returned to work the next day or did not stay out at all, and she did not follow up with staff who called in ill with GI symptoms to confirm symptom resolution before they returned. During an observation of insulin administration to a resident with orders for Lispro insulin 5 units SQ before meals if blood glucose was greater than 200, an LPN prepared and administered the insulin and disposed of the used needle without wearing gloves. The LPN confirmed she forgot to apply gloves, and the DON stated staff were expected to wear gloves when administering insulin or performing tasks with potential exposure to blood or body fluids.
Infection Preventionist Oversight and Surveillance Documentation Deficiency
Penalty
Summary
The facility failed to ensure appropriate oversight by the infection preventionist for the infection prevention and control program. Review of the monthly infection surveillance and staff call-in logs for August, September, and October 2025 showed missing and incomplete documentation. The resident surveillance logs did not include a map identifying the location of infections, did not identify residents on enhanced barrier precautions, and listed residents as being on standard precautions only. The August log identified 6 UTIs, 2 skin infections, and 1 fungal infection; the September log identified 3 UTIs, 3 skin infections, and 3 respiratory infections; and the October log identified 6 residents with urinary infection symptoms, 3 with respiratory symptoms, 1 with GI symptoms, and 4 with skin infections. The logs also did not consistently identify medications prescribed, including dose, frequency, duration, or whether an antibiotic time out had been completed. The staff illness logs were also incomplete. In August 2025, the log identified staff who called in with nausea and vomiting, diarrhea and fever, and upper respiratory symptoms and fever, but did not show when symptoms resolved, the last day worked, or when staff returned to work. Similar omissions were found in September and October 2025, with staff call-ins for GI symptoms, respiratory symptoms, and other illness, but no documentation of symptom resolution, last day worked, or return-to-work date. During interview on 11/17/25 at 3:00 p.m., the infection preventionist agreed the resident infection log and staff illness log were missing information and stated that several staff returned to work the next day or did not stay out at all after calling in ill. She also stated she did not follow up with staff who reported GI symptoms to confirm symptom resolution before return to work, and that she received staff illness information only at the end of each pay period, which made tracking illness difficult. She acknowledged she was aware of concerns with tracking and trending but had not implemented changes to ensure surveillance was thoroughly documented, and agreed she had not provided oversight as the infection preventionist of the infection control program.
Failure to Assess and Document Right Wrist Splint
Penalty
Summary
The facility failed to accurately assess 1 resident for a wrist brace/splint that was present upon admission. The resident’s 10/28/25 5-day admission MDS identified intact cognition, assistance needed from 1 staff for ADLs and transfers, an indwelling Foley catheter, and diagnoses including diabetes type II, high blood pressure, cellulitis of the left lower leg, lymphedema, morbid obesity, weakness, urinary retention, disorders of bone density, and heart failure. However, the MDS did not include the daily use of a glove and wrist splint on the resident’s right wrist, which had been worn since admission. Observation from 10/27/25 through 10/29/25 noted the resident wearing a protective glove under a wrist splint on the right wrist. During interview, the resident stated she had a bone infection of the right wrist and wore the glove and splint because of that, and she reported she had worn the splint for a long time and had been wearing it when admitted and every day since then. She also stated no staff had ever asked her about the brace. The resident’s care plan, physician orders, MAR, TAR, and Nursing Admit Re-Admit Data Collection form did not mention the glove or wrist splint, and the form did not identify any restriction of mobility of the right hand and wrist. RN-B stated she was not aware the resident had been admitted with or was currently using a right wrist splint, and RN-A stated a resident admitted with a splint or other device should be assessed, an order obtained, and documentation placed in the care plan; she confirmed this was not present in the medical record and had not been assessed at admission.
Inaccurate Documentation and Unclear Treatment Order for Lymphedema Boots
Penalty
Summary
The facility failed to ensure staff clarified a treatment order and accurately documented administration of lymphedema boots for one resident with physician orders for the treatment. The resident had Alzheimer's disease, depression, moderately impaired cognition, required substantial assistance with cares, total assistance with toileting, and had documented wandering, hallucinations, delusions, and behavioral symptoms. The resident also had diagnoses of chronic venous disease of the left lower extremity status post left great saphenous vein ablation, and was ordered to continue compression socks and use lymphedema pumps. The resident's physician-related referral paperwork contained handwritten instructions to place the resident in a recliner after lunch with legs elevated for 15 to 20 minutes and to ensure the resident was using lymphedema pumps. The November TAR listed orders to offer the resident a recliner after noon meal and apply the lymphedema pumps, and to use the pumps for 1 hour daily at HS and as needed. However, observations on multiple occasions showed the resident seated without lymphedema boots on, including after lunch and later in the evening, despite the TAR being marked as completed on those days. The TAR also showed daily completion entries through most of the month, with only two days marked refused and one day without charting. Interviews with nursing staff showed the resident often refused the boots and became combative when staff attempted to apply them. One LPN stated she would sometimes mark the treatment as administered before attempting to apply the boots and then forget to change the entry if the resident refused. Another LPN stated she charted the recliner portion as yes because the resident had been offered the recliner, not because the treatment had actually been administered, and said the order may have needed clarification. The interim DON acknowledged the documentation could be interpreted two ways and confirmed staff were not accurately documenting in the medical record and were charting prior to completing the task. Facility policy stated documentation must occur after the event and that unclear orders must be clarified rather than guessed.
Failure to Monitor Antibiotic Use and Complete Antibiotic Time Outs
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included protocols and a system to monitor antibiotic use. For 2 of 3 residents reviewed, there was no indication that an antibiotic time out had been completed after antibiotics were started. R35’s quarterly MDS identified moderately impaired cognition, diagnoses of heart failure, diabetes mellitus, and dementia, and that he was independent with ADLs. His MAR showed cephalexin 500 mg three times daily from 8/11/25 to 8/19/25, and the monthly infection log identified that he had been prescribed an antibiotic for a UTI on 8/11/25, but the log did not show that an antibiotic time out was completed. R42’s quarterly MDS identified severely impaired cognition, diagnoses of dementia and Parkinson’s disease, and dependence on staff for ADLs. His MAR showed cefdinir 300 mg by mouth twice daily from 9/24/25 to 9/30/25, and the monthly infection log identified an upper respiratory infection with onset on 9/21/25 and that he was prescribed an antibiotic, with the infection later resolved on 10/31/25. The infection log also lacked any indication that an antibiotic time out had been completed. The infection preventionist stated on 11/17/25 that no antibiotic time out was sent to the physician for R35 or R42, and that staff were supposed to add a nursing order on the TAR to complete a time out 48 hours after the resident started the new antibiotic.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met as outlined in their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Inadequate Staffing Levels on Weekends
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of its residents, as required by their resident census, care levels, and individual plans of care. During the review of the Payroll Based Journal Report for the period from April 1, 2024, to June 30, 2024, it was identified that the facility submitted weekend staffing data that was excessively low. Specifically, the facility did not meet the required staffing numbers for four out of eight weekend evening shifts. On these occasions, the facility was short of the necessary nursing assistants (NAs) and trained medication aides (TMAs) needed to provide care and services to the residents. Interviews with the administrator and the director of nursing (DON) revealed that the facility included contract staff in their PBJ report but were uncertain why it triggered a deficiency. They reported using a computerized program called On Shift to notify staff of open shifts and attempted to fill these shifts by calling unscheduled staff, using contract staff, or mandating staff to work extended hours. Despite these efforts, the facility's assessment and documentation did not indicate that these approaches were effectively utilized to fill the shifts when staffing numbers could not be attained.
Failure to Reconcile Controlled Substances in Refrigerator
Penalty
Summary
The facility failed to ensure a system for periodic reconciliation of controlled substances stored in a refrigerator as part of their emergency kit. During an observation and interview, it was noted that the refrigerator in the medication room was unlocked, containing a plastic container with a breakaway tag. Inside the container were controlled substances, including morphine liquid, Tramadol tablets, and lorazepam vials. The registered nurse (RN) indicated that since switching pharmacies a few months ago, they had not been counting the narcotics or verifying the security of the lock for medications kept in the refrigerator. Further interviews with a trained medication aide (TMA) and a licensed practical nurse (LPN) revealed that they did not participate in counting the narcotics in the refrigerator or verifying the lock's integrity. The director of nursing confirmed that the narcotics in the refrigerator had not been reconciled or had their locks verified since the new pharmacy took over. The facility's policy required controlled drugs to be stored in separate, locked compartments and reconciled at least daily, which was not being followed.
Failure to Notify Resident's Family of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident and their representative in writing about the bed hold policy, including any potential costs, at the time of the resident's transfer to the hospital. The resident, who had severe cognitive impairment and Alzheimer's disease, was transferred to the hospital after being found with unstable vital signs and shortness of breath. Although the family was informed of the hospital transfer, there was no documentation indicating that the bed hold policy was discussed or provided to them. Interviews with facility staff revealed that the usual practice was to verbally confirm the bed hold with the family and have them sign the form at their convenience. However, in this case, the director of nursing confirmed that the bed hold notice was not discussed or provided to the family when the resident was discharged to the hospital. The facility's policy required that the bed hold policy be sent with the resident to the hospital and provided to the family within 24 hours of the transfer, which was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as recommended by the CDC for two residents with indwelling devices or multi-drug-resistant organisms (MDRO). One resident, who had a gastrostomy tube, did not have EBP precautions included in their care plan. During observations, a registered nurse and a nursing assistant did not consistently use gowns and gloves for high-contact care activities, such as assisting with toileting and perineal care, despite signage indicating the need for such precautions. The staff believed gowns were only necessary for procedures related to the gastrostomy tube. Another resident, colonized with an MDRO, had a care plan that required EBP for high-contact activities. However, staff only used gowns and gloves when toileting the resident, not for other personal care activities. The director of nursing, also the infection preventionist, was unaware of the need for gowns and gloves beyond specific situations and was not aware of the contact precautions signage in the resident's room. The facility's policy stated that EBP should be used for all high-contact activities, but this was not followed in practice.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Edgerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Pipestone | 13.4 mi | ★★★★★ | 1 | 1 |
| Mn Veterans Home - Luverne | 15 mi | ★★★★★ | 5 | 0 |
| Good Samaritan Society - Mary Jane Brown | 16 mi | ★★★★★ | 8 | 0 |
| Palisade Healthcare Center | 21 mi | ★★★★★ | 5 | 1 |
| Riverview Healthcare Center | 25.3 mi | ★★★★★ | 11 | 1 |
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