The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited May 2026 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
Holton Manor
ELKHORN, WI · Medicare-certified · 60 beds
In good standing
Non-profitChain member
Data as of September 1, 2026
2 of 5 overall
Holton Manor in Elkhorn, WI has a 2 out of 5 overall rating, with a 2-star health inspection rating, 3-star staffing, and 4-star quality measures. It reported 4.31 nurse staffing hours per resident per day, slightly above the 4.1 federal benchmark, had no fines in the last 24 months, and recent inspection citations included pressure ulcer care, accident hazards/supervision, and following treatment and care orders.
Facility ratings
Health inspections
Staffing
4.3111 hrs/resident/day
Quality measures
Last inspection: May 6, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.3111.
Staffing detail
- Registered nurses
- 0.63
- Licensed practical nurses
- 0.78
- Nurse aides
- 2.90
- Weekend nursing
- 3.87
Hours per resident per day.
Total staff turnover: 52%
Registered nurse turnover: 31%
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%24%Worsening
Residents with a fall causing major injury
2.6%0%Improving
Residents with pressure ulcers (bedsores)
2.2%8.4%Worsening
Residents with a urinary tract infection
0%0%No change
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
3.7%25%Worsening
Residents whose ability to walk got worse
—24.4%—
Long-stay residents on antianxiety or sleep medication
14.3%22.6%Worsening
Short-stay residents newly given an antipsychotic
1%1%No change
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
24.8%22.8%Improving
Residents with depressive symptoms
2.8%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
99.3%99.4%No change
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited May 2026 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
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
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited May 2026 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: F
The nursing home failed to ensure a qualified person was assigned to oversee infection prevention and control. Cited May 2026 — widespread issue, potential for harm.
View the original federal record
F-Tag 882 — 42 CFR §483.80 — S/S: F
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
- 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 · 1.7 stars avg
- Occupancy
- 54.2 residents on an average day (90% 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.