EAST TROY MANOR
Open-data reference.
EAST TROY MANOR is a non profit - corporation facility in EAST TROY, WI with 50 certified beds and a 1-star overall CMS rating. The facility has 31 deficiency records on file. Total penalties: $51K.
3271 NORTH ST, EAST TROY, WI 53120
Phone: 2626423995
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525561
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 50
- Residents
- 40
- In Hospital
- No
- County
- Walworth
- Last Inspection
- Jan 8, 2026
Staffing Data
- RN Hours
- 0.64 (nat'l avg: 0.68)
- LPN Hours
- 0.79
- CNA Hours
- 3.26
- Total Nursing Hours
- 4.68 (nat'l avg: 3.89)
- PT Hours
- 0.02
- Nursing Turnover
- 59.6%
- RN Turnover
- 28.6%
What the CMS Record Reveals About EAST TROY MANOR
EAST TROY MANOR operates 50 certified beds in EAST TROY, WI with approximately 40 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (4★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 31 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 4 penalties totaling $51K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.68 total nursing hours per resident day (national average 3.89), with RN coverage at 0.64 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, EAST TROY MANOR falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 59.6%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (31 most recent)
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Aug 18, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 18, 2025
Provide training in compliance and ethics.
Category: Administration Deficiencies
Corrected: Aug 18, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Category: Infection Control Deficiencies
Corrected: Aug 18, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Aug 18, 2025
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 18, 2025
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Category: Resident Rights Deficiencies
Corrected: Aug 18, 2025
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Category: Administration Deficiencies
Corrected: Aug 18, 2025
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 18, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 18, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: May 7, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: May 7, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 7, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 13, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 13, 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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 13, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 13, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 13, 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.
Category: Resident Rights Deficiencies
Corrected: Sep 13, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Sep 13, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 13, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Sep 13, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 9, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Aug 9, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Aug 9, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 9, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 9, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 9, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 9, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 25, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Apr 25, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 12.6% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.9% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.6% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.3% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 96.7% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 8.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 18.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 97.3% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 92.7% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.6% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 14.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 11.7% | Yes |
Penalty History 4 penalties totaling $51K
| Date | Type | Amount |
|---|---|---|
| Aug 15, 2024 | Fine | $22K |
| Nov 20, 2023 | Fine | $2K |
| Oct 30, 2023 | Fine | $4K |
| Jul 12, 2023 | Fine | $23K |
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County Health Data
Health outcomes, access, and quality metrics for Walworth on PlainHealth
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.