East Troy Manor
3271 North St, East Troy, WI 53120 · Walworth County · 50 certified beds · avg 42 residents/day · certified since Apr 1, 1995
Part of chain: WISCONSIN ILLINOIS SENIOR HOUSING, INC. (7 facilities, chain avg rating 1.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 24, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 18, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 15, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 13, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 15, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 13, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 12, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 9, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 24, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint |
| Jul 24, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Apr 1, 2025 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Apr 1, 2025 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Apr 1, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 15, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 15, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 15, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 12, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 12, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jul 12, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 1 | G ▲ |
| 2024 | 9 | 2 | J ▲ |
| 2025 | 13 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $129,433.
| Date | Type | Amount / length |
|---|---|---|
| Jul 24, 2025 | Fine | $101,220 |
| Aug 15, 2024 | Fine | $21,902 |
| Nov 20, 2023 | Fine | $2,117 |
| Oct 30, 2023 | Fine | $4,194 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.79 | 4.29 | 3.95 | bottom 38% in Wisconsin; top 49% in the U.S. |
| Registered Nurse hours | 0.71 | 1.01 | 0.69 | bottom 23% in Wisconsin; top 35% in the U.S. |
| Weekend total nurse staffing | 3.10 | 3.84 | 3.50 | bottom 24% in Wisconsin; bottom 36% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.33 | 0.68 | 0.48 | bottom 8% in Wisconsin; bottom 39% in the U.S. |
| Total nursing staff turnover (%) | 68.5 | 46.9 | 45.8 | bottom 8% in Wisconsin; bottom 7% in the U.S. |
| RN turnover (%) | 33.3 | 39.7 | 42.9 | top 40% in Wisconsin; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.76, RN 0.71, weekend 3.08. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Carriage Healthcare Companies INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/15/2001 |
| Carriage Healthcare Companies INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/06/2025 |
| Dupont, Lori | Individual | Corporate Director | NOT APPLICABLE | 01/25/2016 |
| Gehler, Miriam | Individual | Corporate Director | NOT APPLICABLE | 03/14/2011 |
| Gerlach, Keri | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| HBT It LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| HBT It LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/18/2025 |
| JT and Associates LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2010 |
| JT and Associates LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/05/2026 |
| Kerwin, Andrew | Individual | Corporate Director | NOT APPLICABLE | 06/26/2009 |
| Kumar, Rajeev Shiva | Individual | Corporate Director | NOT APPLICABLE | 04/24/2012 |
| Lacke (carrig), Karen | Individual | Corporate Director | NOT APPLICABLE | 01/01/2016 |
| Leadley, Christie | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/02/2023 |
| Leadley, Christie | Individual | ADP of the SNF | NOT APPLICABLE | 05/02/2023 |
| Lynn, Nicholas | Individual | Corporate Director | NOT APPLICABLE | 03/14/2011 |
| Partners in Wealth Management, INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Partners in Wealth Management, INC | Organization | ADP of the SNF | NOT APPLICABLE | 08/18/2025 |
| Pinion, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/1995 |
| Pinion, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/18/2025 |
| Rehab Solutions Group, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What ongoing training do your direct care staff receive each year?"
- "How and how often are staff trained on residents' rights?"
- "What training do all staff get on dementia care and on spotting and reporting abuse?"
- "How do frontline staff report care problems, and how does your quality improvement program act on them?"
- "How are staff trained on infection control, and how often is that training refreshed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Lindengrove Mukwonago | 4.3 mi | Mukwonago, WI | ★★☆☆☆ | 3/5 | |
| Lakeland Health Care Ctr | 9.6 mi | Elkhorn, WI | ★★★☆☆ | 2/5 | abuse |
| Holton Manor | 9.8 mi | Elkhorn, WI | ★★☆☆☆ | 2/5 | |
| Burlington Health and Rehabilitation Center | 11.4 mi | Burlington, WI | ★☆☆☆☆ | 1/5 | |
| Geneva Lake Manor | 14.0 mi | Lake Geneva, WI | ★☆☆☆☆ | 1/5 | |
| Golden Years of Lake Geneva | 15.0 mi | Lake Geneva, WI | ★★★★☆ | 5/5 | |
| Delavan Health Services | 15.6 mi | Delavan, WI | ★★★★☆ | 4/5 | |
| Williams Bay Health Services | 16.0 mi | Williams Bay, WI | ★☆☆☆☆ | 1/5 | |
| Masonic Center for Health & Rehab INC. | 16.0 mi | Dousman, WI | ★★★★★ | 5/5 | |
| Tudor Oaks Health Center | 16.6 mi | Muskego, WI | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525561.