Map showing the location of EAST TROY MANOR in EAST TROY, Wisconsin
3271 NORTH ST, EAST TROY, WI, 53120

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinLowest tier among peers321 rated homes · average 3.0★
  • Walworth CountyLowest tier among peers7 rated homes · average 3.0★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs WI avg
  • StaffingCan add or remove a star4★+0.3 vs WI avg
  • Quality measuresCan add or remove a star4★+0.9 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 35% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 58% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.68hrsAbove 75% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.64hrsAbove only 15% of peersWI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better60%Above only 21% of peersWI avg48%RN turnover29%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$51,418Above only 24% of peersWI avg$41,875Fines · denials4 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
31citations
5inspection dates
1actual harm (G–I)
3immediate jeopardy (J–L)
Jul 24, 2025most recent

Citations by monthMar 2022 – Jul 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jul 24, 202510 citationsCycle 1worst J · immediate jeopardy
  1. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Aug 18, 2025
  2. F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationF · widespreadCorrected Aug 18, 2025
  3. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationF · widespreadCorrected Aug 18, 2025
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Aug 18, 2025
  5. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Aug 18, 2025
  6. F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationF · widespreadCorrected Aug 18, 2025
  7. F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsF · widespreadCorrected Aug 18, 2025
  8. F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Aug 18, 2025
  9. F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlF · widespreadCorrected Aug 18, 2025
  10. F946Provide training in compliance and ethics.AdministrationF · widespreadCorrected Aug 18, 2025
Apr 1, 20253 citationsCycle 1worst E · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 7, 2025
  2. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected May 7, 2025
  3. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected May 7, 2025
Aug 15, 20249 citationsCycle 1worst J · immediate jeopardy$21,902
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 13, 2024
  2. 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.Resident RightsD · isolatedCorrected Sep 13, 2024
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareJ · isolatedCorrected Sep 13, 2024
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 13, 2024
  5. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Sep 13, 2024
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 13, 2024
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Sep 13, 2024
  8. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Sep 13, 2024
  9. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Sep 13, 2024
Jul 12, 20237 citationsCycle 2worst G · actual harm$23,205
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Aug 9, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 9, 2023
  3. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Aug 9, 2023
  4. F700Try 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.Quality of Life and CareD · isolatedCorrected Aug 9, 2023
  5. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Aug 9, 2023
  6. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Aug 9, 2023
  7. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Aug 9, 2023
Mar 31, 20222 citationsCycle 3worst F · no actual harm
  1. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 25, 2022
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 25, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.68hrsAbove 75% of peers+0.49 vs WI avg
  • Registered nursesRN hours only0.64hrsAbove only 15% of peers−0.32 vs WI avg
  • Licensed practical nursesLPN hours0.79hrs
  • Nurse aidesCNA hours3.26hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.01hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better60%Above only 21% of peersWI avg 48%
  • RN turnoverRegistered nurses only29%Not ranked by CMS
  • Administrators who leftIn the past year
  • Occupancy50 certified beds · ~40 residents a day79%Above 60% of peersWI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $51,418In fines
  • 4Fines
  • 0Payment denials
  • $41,875WI avg in fines
Above only 24% of peersFewer fines than 24% of rated homes in Wisconsin

Actions on record

  1. Aug 15, 2024Civil money penalty$21,902
  2. Nov 20, 2023Civil money penalty$2,117
  3. Oct 30, 2023Civil money penalty$4,194
  4. Jul 12, 2023Civil money penalty$23,205

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Wisconsin Illinois Senior Housing, INC.7 facilities in the chain2.0★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Operational or managerial control
  • Carriage Healthcare Companies INC
  • Robert Siebel
Corporate directors
  • Lori Dupont
  • Miriam Gehler
  • Keri Gerlach
  • Andrew Kerwin
  • Rajeev Kumar
  • Karen Lacke (carrig)
  • Nicholas Lynn
Contracted managers
  • Stephanie Sherman
  • Robert Siebel
Managing employees
  • Stephanie Sherman

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525561 · 3271 NORTH ST, EAST TROY, WI, 53120.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Walworth County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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