Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
East Troy Manor
EAST TROY, WI · 50 certified beds · Last Life Safety survey January 8, 2026
CMS Certification Number 525561 · first certified April 1995
Ownership
Operated by WISCONSIN ILLINOIS SENIOR HOUSING, INC. · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
29 citations — more than 84% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 12. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens February 2027 — about 5 months from now. This facility’s last Life Safety survey was January 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 29 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 12, 2023 | 9 |
| August 15, 2024 | 15 |
| January 8, 2026 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-01-08 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2026-01-08 |
| K-0222 | 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. | 2 | 2024-08-15 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2026-01-08 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 2 | 2026-01-08 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-08-15 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2026-01-08 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2023-07-12 |
What the citations cover
- Smoke Deficiencies 12
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 5
- Egress Deficiencies 4
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 1 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 8, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (February 8, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 8, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 8, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 8, 2026) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (February 8, 2026) |
August 15, 2024 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0222 | 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. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Waiver has been granted (February 26, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 29, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 4, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (September 5, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 5, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 13, 2024) |
July 12, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (September 22, 2023) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (August 9, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.