The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited October 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: G
Nursing home report
Holton Manor
ELKHORN, WI · Medicare-certified · 60 beds
In good standing
Non-profitChain member
5 of 5 overall
Holton Manor in Elkhorn, WI has a 5 out of 5 overall rating, with 5 stars for health inspections, 4 stars for staffing, and 4 stars for quality measures. It reported 4.23 nurse staffing hours per resident per day versus the 4.1 federal benchmark, had $0 fines in the last 24 months, and recent inspection citations included treatment/care orders, aide training in dementia care and abuse prevention, and accident hazard/supervision issues.
Facility ratings
Health inspections
Staffing
4.2316 hrs/resident/day
Quality measures
Last inspection: March 20, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.2316.
Staffing detail
- Registered nurses
- 0.77
- Licensed practical nurses
- 0.64
- Nurse aides
- 2.82
- Weekend nursing
- 3.71
Hours per resident per day.
Total staff turnover: 51%
Registered nurse turnover: 17%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
20.8%16%Improving
Residents with a fall causing major injury
0%0%No change
Residents with pressure ulcers (bedsores)
4.7%4%Improving
Residents with a urinary tract infection
3%0%Improving
Residents who lost too much weight
0%0%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
13.6%20.8%Worsening
Residents whose ability to walk got worse
—20.9%—
Long-stay residents on antianxiety or sleep medication
16.7%23.1%Worsening
Short-stay residents newly given an antipsychotic
1.9%1%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
7%14.6%Worsening
Residents with depressive symptoms
10%0%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—99.3%—
Short-stay residents given the pneumonia vaccine
100%99.4%Worsening
What the inspectors found
The home failed to ensure nurse aides had the skills and training needed to care for residents safely, including dementia care and abuse prevention. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 947 — 42 CFR §483.95 — S/S: E
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited February 2024 — limited pattern, potential for harm.
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F-Tag 689 — 42 CFR §483.25(d) — S/S: E
The home failed to ensure nurses and nurse aides had the needed skills to care for each resident and support their well-being. Cited March 2025 — isolated incident, potential for harm.
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F-Tag 726 — 42 CFR §483.35 — S/S: D
The home failed to protect residents’ right to complain without fear and did not ensure grievances were handled promptly. Cited October 2023 — isolated incident, potential for harm.
View the original federal record
F-Tag 585 — 42 CFR §483.10 — S/S: D
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- Non profit - Corporation
- Chain
- Part of WISCONSIN ILLINOIS SENIOR HOUSING, INC. · 7 homes · 1.9 stars avg
- Occupancy
- 55.3 residents on an average day (92% of 60 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 32 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.