C
LINDENGROVE MUKWONAGO
64/100 score
1.15 hrs RN staffing
14 deficiencies
EAST TROY MANOR
3271 NORTH ST, EAST TROY, WI 53120
D
Facility Assessment
Inspectors recorded 4 citations at the actual-harm level or worse in the last three survey cycles.
At or above the 2024 benchmark — elevated deficiency count.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.64 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
29
Outstanding
0
Actual harm or worse (G–L)
4
|
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★★☆ (4/5)
Staffing: ★★★★☆ (4/5)
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NursingHomeGrade Score
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45/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
3 immediate jeopardy, 1 actual harm issues found among 29 total deficiencies. 29 corrected.
Most recent inspection (July 24, 2025)
F
Potential harm — widespread
F0941
Status: Corrected
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
F
Potential harm — widespread
F0944
Status: Corrected
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
F
Potential harm — widespread
F0946
Status: Corrected
Provide training in compliance and ethics.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
F
Potential harm — widespread
F0949
Status: Corrected
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
E
Potential harm — pattern
F0867
Status: Corrected
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected May 7, 2025
F
Potential harm — widespread
F0943
Status: Corrected
Give 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 Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
F
Potential harm — widespread
F0945
Status: Corrected
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
C
No harm — widespread
F0732
Status: Corrected
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
F
Potential harm — widespread
F0947
Status: Corrected
Ensure 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 Services Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
E
Potential harm — pattern
F0947
Status: Corrected
Ensure 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 Services Deficiencies — Deficient, Provider has date of correction, corrected May 7, 2025
J
Immediate jeopardy — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 7, 2025
F
Potential harm — widespread
F0942
Status: Corrected
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2025
Inspection cycle 2 (August 15, 2024)
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
D
Potential harm — isolated
F0610
Status: Corrected
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
F
Potential harm — widespread
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
D
Potential harm — isolated
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
J
Immediate jeopardy — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
J
Immediate jeopardy — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
D
Potential harm — isolated
F0656
Status: Corrected
Develop 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 Planning Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
E
Potential harm — pattern
F0623
Status: Corrected
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
D
Potential harm — isolated
F0625
Status: Corrected
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 Rights Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2024
Inspection cycle 3 (July 12, 2023)
F
Potential harm — widespread
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 9, 2023
D
Potential harm — isolated
F0758
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 9, 2023
D
Potential harm — isolated
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 9, 2023
G
Actual harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 9, 2023
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 9, 2023
D
Potential harm — isolated
F0690
Status: Corrected
Provide 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 Care Deficiencies — Deficient, Provider has date of correction, corrected August 9, 2023
D
Potential harm — isolated
F0700
Status: Corrected
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 9, 2023
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