East Troy Manor

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 50 beds and averages 41.9 residents a day — about 84% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.08 hrs/resident/day on weekends vs 4.04 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.86 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, document review and policy review, the facility failed to ensure that fall risks were assessed and that adequate fall interventions were developed, implemented and revised for one of three residents (Resident (R)2) reviewed for falls. R2 was admitted to the facility following a fall at home where R2 sustained a subdural hematoma. The subdural hematoma was still present and in need of monitoring post admission to the facility. Upon admission, R2 was assessed to be at risk for falls with initial safety interventions including a low bed and frequent rounding (frequency not specified). On 4/20/25 the facility placed a sensor alarm to prevent falls. Progress notes indicate R2 frequently setting off the alarms related to impulsivity and frequent self-transfers. On 4/24/25 R2's Nurse Practitioner noted, in their neuro psych initial evaluation of R2: (R2) is oriented times 1(oriented to self), unable to answer questions appropriately. Walking unsteadily in room while self-transfers to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 of 1 resident (R291) reviewed with a significant change in condition had a comprehensive assessment performed consistent with professional standards of nurse practice (N6, Wisconsin Nurse Practice Act,) the comprehensive person-centered care plan, and the resident's choices. *On [DATE], R291 was having increased difficulty with transfers and eating. The difficulty continued to worsen and on [DATE] at approximately 12:41 a.m., R291 required use of a mechanical lift and had difficulty speaking. The Registered Nurse (RN) on duty did not take vital signs (other than an undocumented pulse oximetry) and did not perform a comprehensive assessment into the change in condition. There was no physician notification of the change in condition. On [DATE] at approximately 7:50 a.m., R291 became unresponsive and was transferred and admitted into the hospital with a diagnosis of severe sepsis. R291 subsequently expired while in the hospital on [DATE]. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that 1 (R24) of 2 residents reviewed was provided adequate supervision and assistance devices to prevent accidents. R24 was identified by the facility as a wander/elopement risk due to altered mental status/dementia in June 2023. The facility did place a Wanderguard bracelet, however, at one point they placed it on the resident's wheelchair even when it was known resident was physically capable of standing up from her wheelchair and ambulating without assistance. Resident was able to elope from the facility and was found outside of the facility on two separate occasions, once when it was raining, and once at 1 am. The facility's failure to provide adequate supervision and proper assistance devices to R24 created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 06/27/2024. The immediate jeopardy was removed on 8/15/24, however, the deficient practice continues at a scope/severity…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-07-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3.) R4 was admitted to the facility on [DATE] and had diagnoses including periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's 2/12/23 quarterly Minimum Data Set (MDS) indicates R4 had rejection of care 1-3 days during the assessment. R4 has a stage 1 or greater pressure injury, is at risk for pressure injuries. The MDS indicates R4 has 1 stage 2 pressure injury. R4's care plan, with a start date of 2/16/23, documented, [name of resident ] has been diagnosed with an infection to wound on the left buttocks, and had interventions including, -Administer medications and treatments as ordered . -Monitor for s/sx (signs /symptoms) of infection worsening or not showing signs of resolve with treatment . -dressing change per orders . Surveyor noted there was not a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0941 — widespread
  Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 6 of 6 direct care staff, chosen at random, received required training on effective communication. Licensed Practical Nurse (LPN)-2, and Certified Nursing Assistants (CNA) CNA1, CNA8, CNA9, CNA10 and CNA11 did not receive effective communication training. This deficient practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents: Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0942 — widespread
  Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received required training on resident rights and responsibilities. Dietary Aide (DA)1 and Certified Nursing Assistants (CNAs), CNA1, CNA8, and CNA9 did not receive required training on resident rights and responsibilities. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0943 — widespread
  Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received training on abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management and resident abuse prevention. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA10 and CNA11 did not receive this required training. This deficient practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0944 — widespread
  Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received required training on Quality Assurance Performance Improvement (QAPI) training. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9 and Dietary Aide (DA)1 did not receive required QAPI training. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0945 — failed to train staff on abuse prevention — widespread
  Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 4 facility staff chosen at random, received required training on infection prevention and control. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9 and Dietary Aide (DA)1 did not receive required training on infection prevention and control. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0946 — widespread
  Provide training in compliance and ethics.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 5 facility staff, chosen at random, received required training on compliance and ethics which includes training on standards, policies, and procedures of the facility's compliance and ethics program. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA10 and CNA11 and Dietary Aide (DA)1 did not receive the required compliance and ethics training. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-07-24 · tag F0947 — failed to train nurse aides adequately — widespread
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 5 Certified Nursing Assistants (CNAs) reviewed completed the required 12 hours of educational inservice hours. CNA1, CNA8, CNA9, CNA10 and CNA11 did not receive 12 hours of annual inservice education training. This had the potential to affect all 39 Residents who reside in the facility.Findings include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-07-24 · tag F0949 — failed to train staff on dementia and abuse — widespread
  Provide behavior health training consistent with the requirements and as determined by a facility assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure 8 of 8 facility staff, chosen at random, received required training on behavioral health. Licensed Practical Nurse (LPN)2, Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9, CNA10, CNA11, Housekeeper (HK)1, and Dietary Aide (DA)1 did not receive the required behavioral health training. This deficient practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-01 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, facility document review, and facility policy review, the facility failed to establish an effective Quality Assurance and Performance Improvement (QAPI) program that obtained program feedback, utilized data, took action to conduct structured, systematic investigations, and analyzed underlying causes or contributing factors of problems affecting facility-wide processes that impacted quality of care, quality of life, and resident safety. Specifically, the facility QAPI program failed to track and trend falls. Findings included: A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised 02/2020, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. The Policy Interpretation and Implementation revealed, The objectives of the QAPI Program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-01 · tag F0947 — failed to train nurse aides adequately — pattern
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility document review and interview, the facility failed to establish a training program to include an effective system of communication with contracted agency staff related to the level of care a resident requires. Findings included: During an interview on 04/01/2025 at 4:35 PM, the Administrator stated that contracted agency staff were required to read resident care information contained in a binder prior to their first shift, and were to use care cards to determine a resident's transfer status. She stated she would provide the agency binder. An untitled facility document provided by the Administrator from a binder the facility used for agency staff, dated 01/06/2025, revealed, Topic: Care Cards. The document revealed, Care Cards are in residents [sic] rooms in their closet. Cares must be done according to the care card to meet the residents [sic] needs in the safest way possible. The document revealed that Agency CNAs (ACNAs) signed the document; however, ACNA K and ACNA M had not signed the document. During an interview on 03/31/2025 at 5:30 PM, ACNA K stated she was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$129,433 in federal fines across 4 penalties.

• $101,220 — penalty dated 2025-07-24
• $21,902 — penalty dated 2024-08-15
• $2,117 — penalty dated 2023-11-20
• $4,194 — penalty dated 2023-10-30

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to WISCONSIN ILLINOIS SENIOR HOUSING, INC. — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 27 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $71K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in WI