East Troy Manor

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.7 to 4.1 hours per resident per day.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation K0341. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on February 8, 2026.

  CMS has cited this home for K0341 2 times since 2024.

• Citation K0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on February 8, 2026.

  CMS has cited this home for K0761 2 times since 2024.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on February 8, 2026.

  CMS has cited this home for K0353 3 times since 2023.

• Citation K0781. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on February 8, 2026.

• Citation K0345. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on February 8, 2026.

  CMS has cited this home for K0345 2 times since 2024.

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• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 18, 2025.

  CMS has cited this home for F0689 4 times since 2023.

• Citation F0941. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  CMS lists it as corrected on August 18, 2025.

• Citation F0942. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  CMS lists it as corrected on August 18, 2025.

• Citation F0943. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  CMS lists it as corrected on August 18, 2025.

• Citation F0944. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  CMS lists it as corrected on August 18, 2025.

• Citation F0945. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

  CMS lists it as corrected on August 18, 2025.

• Citation F0946. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide training in compliance and ethics.

  CMS lists it as corrected on August 18, 2025.

• Citation F0947. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS lists it as corrected on August 18, 2025.

  CMS has cited this home for F0947 2 times since 2025.

• Citation F0949. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide behavior health training consistent with the requirements and as determined by a facility assessment.

  CMS lists it as corrected on August 18, 2025.

• Citation F0732. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on August 18, 2025.

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CMS fine of $101,220 on July 24, 2025.

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• Fine

  CMS changed the fine from August 15, 2024 from $33,695 to $21,902.

CMS lists this as a complaint inspection.

• Citation F0867. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on May 7, 2025.

• Citation F0947. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS lists it as corrected on May 7, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 7, 2025.

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• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 1 of 5.

CMS lists this as a standard inspection and a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.

• Citation F0684. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on September 13, 2024.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 13, 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 13, 2024.

  CMS has cited this home for F0880 2 times since 2023.

• Citation F0623. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on September 13, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on September 13, 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on September 13, 2024.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 13, 2024.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on September 13, 2024.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 13, 2024.

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CMS lists this as a standard inspection.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on September 13, 2024.

• Citation K0111. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

  CMS lists it as corrected on September 13, 2024.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on September 13, 2024.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on August 29, 2024.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on September 4, 2024.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on September 5, 2024.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on September 5, 2024.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on September 13, 2024.

• Citation K0341. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on February 26, 2025.

• Citation K0345. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on September 13, 2024.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on September 13, 2024.

  CMS has cited this home for K0363 2 times since 2023.

• Citation K0374. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on September 13, 2024.

• Citation K0222. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on September 13, 2024.

  CMS has cited this home for K0222 2 times since 2023.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on September 13, 2024.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on September 13, 2024.

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CMS fine of $21,902 on August 15, 2024.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Fine

  CMS changed the fine from November 20, 2023 from $2,098 to $2,117.

• Fine

  CMS changed the fine from July 12, 2023 from $35,700 to $23,205.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

CMS fine of $2,117 on November 20, 2023.

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CMS fine of $4,194 on October 30, 2023.

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CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

42 of 323 Wisconsin homes (13%) got a citation at the actual harm level in 2023.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on August 9, 2023.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 9, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 9, 2023.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on August 9, 2023.

• Citation F0700. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  CMS lists it as corrected on August 9, 2023.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 9, 2023.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on August 9, 2023.

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CMS lists this as a standard inspection.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 9, 2023.

• Citation K0911. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on August 9, 2023.

• Citation K0919. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on August 9, 2023.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on August 9, 2023.

• Citation K0223. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  CMS lists it as corrected on August 9, 2023.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on August 9, 2023.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on August 9, 2023.

• Citation K0521. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on September 22, 2023.

• Citation K0753. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have restrictions on the use of highly flammable decorations.

  CMS lists it as corrected on August 9, 2023.

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