Holton Manor
645 N Church St, Elkhorn, WI 53121 · Walworth County · 60 certified beds · avg 54 residents/day · certified since Mar 16, 1994
Part of chain: WISCONSIN ILLINOIS SENIOR HOUSING, INC. (7 facilities, chain avg rating 1.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 6, 2026 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 25, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 6, 2026 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 30, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 4, 2023 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 2, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (17)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 6, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 6, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 6, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 6, 2026 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| May 6, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| May 6, 2026 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| May 6, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 6, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 6, 2026 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| May 6, 2026 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Mar 20, 2025 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Mar 20, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Feb 1, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 4, 2023 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 1 | G ▲ |
| 2024 | 1 | 0 | E |
| 2025 | 2 | 0 | E |
| 2026 | 10 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.89 | 4.29 | 3.95 | bottom 42% in Wisconsin; top 44% in the U.S. |
| Registered Nurse hours | 0.57 | 1.01 | 0.69 | bottom 9% in Wisconsin; bottom 48% in the U.S. |
| Weekend total nurse staffing | 3.50 | 3.84 | 3.50 | bottom 42% in Wisconsin; top 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.39 | 0.68 | 0.48 | bottom 16% in Wisconsin; top 49% in the U.S. |
| Total nursing staff turnover (%) | 51.8 | 46.9 | 45.8 | bottom 34% in Wisconsin; bottom 32% in the U.S. |
| RN turnover (%) | 30.8 | 39.7 | 42.9 | top 38% in Wisconsin; top 30% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.31, RN 0.63, weekend 3.87. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Carriage Healthcare Companies INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/15/2001 |
| Dupont, Lori | Individual | Corporate Officer | NOT APPLICABLE | 01/25/2016 |
| Dupont, Lori | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2015 |
| Gehler, Miriam | Individual | Corporate Director | NOT APPLICABLE | 03/14/2011 |
| Gehler, Miriam | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2016 |
| Gerlach, Keri | Individual | Corporate Director | NOT APPLICABLE | 09/24/2019 |
| Gerlach, Keri | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| HBT It LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| JT and Associates LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2010 |
| Kerwin, Andrew | Individual | Corporate Officer | NOT APPLICABLE | 06/26/2009 |
| Kerwin, Andrew | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2016 |
| Kerwin, Andrew | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/08/2026 |
| Kumar, Rajeev Shiva | Individual | Corporate Director | NOT APPLICABLE | 04/24/2012 |
| Kumar, Rajeev Shiva | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/24/2012 |
| Lynn, Nicholas | Individual | Corporate Director | NOT APPLICABLE | 03/14/2011 |
| Lynn, Nicholas | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/14/2011 |
| Oak Medical SC | Organization | ADP of the SNF | NOT APPLICABLE | 01/14/2019 |
| Partners in Wealth Management, INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Pinion, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/1995 |
| Rehab Solutions Group, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is your infection preventionist, and what training do they have?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Lakeland Health Care Ctr | 0.4 mi | Elkhorn, WI | ★★★☆☆ | 2/5 | abuse |
| Delavan Health Services | 5.8 mi | Delavan, WI | ★★★★☆ | 4/5 | |
| Williams Bay Health Services | 7.1 mi | Williams Bay, WI | ★☆☆☆☆ | 1/5 | |
| Geneva Lake Manor | 8.9 mi | Lake Geneva, WI | ★☆☆☆☆ | 1/5 | |
| East Troy Manor | 9.8 mi | East Troy, WI | ★★☆☆☆ | 2/5 | |
| Golden Years of Lake Geneva | 10.2 mi | Lake Geneva, WI | ★★★★☆ | 5/5 | |
| Lindengrove Mukwonago | 13.2 mi | Mukwonago, WI | ★★☆☆☆ | 3/5 | |
| Burlington Health and Rehabilitation Center | 14.5 mi | Burlington, WI | ★☆☆☆☆ | 1/5 | |
| Alden Meadow Park HCC | 18.3 mi | Clinton, WI | ★★★☆☆ | 3/5 | |
| Mercy Harvard Hospital Care Center | 19.5 mi | Harvard, IL | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525541.