EAST TROY MANOR
3271 NORTH ST, EAST TROY, WI 53120 · CCN 525561
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★★★☆ 4
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- Non profit - Corporation
- Certified beds
- 50
- Avg residents/day
- 39.5
- Phone
- 2626423995
Inspection history vs Wisconsin & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Wisconsin avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2026-01-08 | 13 | 9.8 | 9.5 | +3.2 worse |
| 2 | 2024-08-15 | 9 | 9.2 | 9.8 | -0.2 better |
| 3 | 2023-07-12 | 7 | 8.3 | 9.3 | -1.3 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Quality of life and care | 2 |
| Nursing and physician services | 3 |
| Resident rights | 1 |
| Administration | 5 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 4.68 | 59.6% |
| RN staffing (reported) | 0.64 | 28.6% |
| Total nurse staffing (adjusted) | 4.75 | — |
Fines & penalties
- Total fines
- $51,418
- Number of fines
- 4
- Number of penalties
- 4
- Payment denials
- 0
Chain
- Chain
- WISCONSIN ILLINOIS SENIOR HOUSING, INC.
- Facilities in chain
- 7
- Chain avg overall
- 2.00 / 5
Inspection citations (29)3 immediate jeopardy1 actual harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-07-24 · Health · corrected 2025-08-18
Immediate jeopardy
- CF0732Post nurse staffing information every day.2025-07-24 · Health · corrected 2025-08-18
Potential for minimal harm
- FF0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- FF0942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- FF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- FF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- FF0945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- FF0946Provide training in compliance and ethics.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- FF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- FF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2025-07-24 · Health · corrected 2025-08-18
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-04-01 · Health · corrected 2025-05-07
Potential for more than minimal harm
- EF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2025-04-01 · Health · corrected 2025-05-07
Potential for more than minimal harm
- EF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2025-04-01 · Health · corrected 2025-05-07
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-08-15 · Health · corrected 2024-09-13
Potential for more than minimal harm
- DF0610Respond appropriately to all alleged violations.2024-08-15 · Health · corrected 2024-09-13
Potential for more than minimal harm
- EF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-08-15 · Health · corrected 2024-09-13
Potential for more than minimal harm
- DF0625Notify 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.2024-08-15 · Health · corrected 2024-09-13
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-08-15 · Health · corrected 2024-09-13
Potential for more than minimal harm
- JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-08-15 · Health · corrected 2024-09-13
Immediate jeopardy
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-08-15 · Health · corrected 2024-09-13
Immediate jeopardy
- DF0761Ensure 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.2024-08-15 · Health · corrected 2024-09-13
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2024-08-15 · Health · corrected 2024-09-13
Potential for more than minimal harm
- GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-07-12 · Health · corrected 2023-08-09
Actual harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-07-12 · Health · corrected 2023-08-09
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2023-07-12 · Health · corrected 2023-08-09
Potential for more than minimal harm
- DF0700Try 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.2023-07-12 · Health · corrected 2023-08-09
Potential for more than minimal harm
- DF0758Implement 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.2023-07-12 · Health · corrected 2023-08-09
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2023-07-12 · Health · corrected 2023-08-09
Potential for more than minimal harm
- FF0880Provide and implement an infection prevention and control program.2023-07-12 · Health · corrected 2023-08-09
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| CARRIAGE HEALTHCARE COMPANIES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2001-02-15 |
| SIEBEL, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2015-05-01 |
| DUPONT, LORI | Individual | CORPORATE DIRECTOR | — | 2016-01-25 |
| GEHLER, MIRIAM | Individual | CORPORATE DIRECTOR | — | 2011-03-14 |
| GERLACH, KERI | Individual | CORPORATE DIRECTOR | — | 2019-01-01 |
| KERWIN, ANDREW | Individual | CORPORATE DIRECTOR | — | 2009-06-26 |
| KUMAR, RAJEEV | Individual | CORPORATE DIRECTOR | — | 2012-04-24 |
| LACKE (CARRIG), KAREN | Individual | CORPORATE DIRECTOR | — | 2016-01-01 |
| LYNN, NICHOLAS | Individual | CORPORATE DIRECTOR | — | 2011-03-14 |
| SHERMAN, STEPHANIE | Individual | CONTRACTED MANAGING EMPLOYEE | — | 2015-05-01 |
| SIEBEL, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | 2015-05-01 |
| SHERMAN, STEPHANIE | Individual | W-2 MANAGING EMPLOYEE | — | 2013-07-10 |
Other facilities in EAST TROY
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.