East Troy Manor
3271 North St · East Troy, WI · 53120 · 2626423995
50 certified beds Non profit - Corporation Chain: Wisconsin Illinois Senior Housing, Inc.
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $21,902 in fines in the last 24 months.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
70% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.08 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.81 | 0.55–0.75 |
| Weekend hours / resident-day | 3.29 | ≈ weekday level |
| Nursing turnover / year | 70% | median 45% |
| Fines (3-yr window) | 4 · $51,418 |
Inspection citations (29 in the current record)
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Immediate jeopardy · J July 24, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 18, 2025 · Quality of Life and Care
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Potential for harm · F July 24, 2025 · found via complaint
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected August 18, 2025 · Administration
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Potential for harm · F July 24, 2025 · found via complaint
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected August 18, 2025 · Resident Rights
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Potential for harm · F July 24, 2025 · found via complaint
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected August 18, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F July 24, 2025 · found via complaint
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected August 18, 2025 · Administration
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Potential for harm · F July 24, 2025 · found via complaint
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected August 18, 2025 · Infection Control
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Potential for harm · F July 24, 2025 · found via complaint
Provide training in compliance and ethics.
Corrected August 18, 2025 · Administration
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Potential for harm · F July 24, 2025 · found via complaint
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected August 18, 2025 · Nursing and Physician Services
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Potential for harm · F July 24, 2025 · found via complaint
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected August 18, 2025 · Administration
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No harm found · C July 24, 2025 · found via complaint
Post nurse staffing information every day.
Corrected August 18, 2025 · Nursing and Physician Services
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Potential for harm · D April 1, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 7, 2025 · Quality of Life and Care
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Potential for harm · E April 1, 2025 · found via complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected May 7, 2025 · Administration
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Potential for harm · E April 1, 2025 · found via complaint
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected May 7, 2025 · Nursing and Physician Services
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Immediate jeopardy · J August 15, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 13, 2024 · Quality of Life and Care
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Immediate jeopardy · J August 15, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 13, 2024 · Quality of Life and Care
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Potential for harm · D August 15, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 13, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 15, 2024
Respond appropriately to all alleged violations.
Corrected September 13, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 15, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected September 13, 2024 · Resident Rights
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Potential for harm · D August 15, 2024
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected September 13, 2024 · Resident Rights
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Potential for harm · D August 15, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 13, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 15, 2024
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 September 13, 2024 · Pharmacy Service
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Potential for harm · F August 15, 2024
Provide and implement an infection prevention and control program.
Corrected September 13, 2024 · Infection Control
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Actual harm · G July 12, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected August 9, 2023 · Quality of Life and Care
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Potential for harm · D July 12, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 9, 2023 · Quality of Life and Care
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Potential for harm · D July 12, 2023
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 August 9, 2023 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 15, 2024 | Fine | $21,902 |
| November 20, 2023 | Fine | $2,117 |
| October 30, 2023 | Fine | $4,194 |
| July 12, 2023 | Fine | $23,205 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525561 · certified since April 1, 1995. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.