Lakeland Health Care Ctr
1922 Cty Rd Nn, Elkhorn, WI 53121 · Walworth County · 90 certified beds · avg 81 residents/day · certified since Aug 1, 1997
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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)
▲ Immediate jeopardy, one-off · Sep 2, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 25, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, repeated · Nov 21, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 15, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 21, 2023 · F-0744 · triggered by a complaint
The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 15, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 2, 2025 · F-0744 · triggered by a complaint
The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
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: Sep 17, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (21)
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 |
|---|---|---|
| Jan 26, 2026 | D · Potential for harm, one-off | 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. |
| Sep 2, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 2, 2025 | ▲ G · Actual harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Jul 7, 2025 | 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 |
| Jul 7, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Aug 29, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 29, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 29, 2024 | 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 |
| Aug 29, 2024 | D · Potential for 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. · from a complaint |
| Aug 29, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Aug 29, 2024 | D · Potential for harm, one-off | 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. |
| Nov 21, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 21, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Nov 21, 2023 | E · Potential for harm, repeated | 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 |
| Nov 21, 2023 | E · Potential for harm, repeated | 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 |
| Aug 8, 2023 | D · Potential for 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 |
| Jun 7, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 7, 2023 | D · Potential for 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. |
| Jun 7, 2023 | D · Potential for 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. |
| Jun 7, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Jun 7, 2023 | D · Potential for harm, one-off | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 10 | 2 | K ▲ |
| 2024 | 6 | 0 | D |
| 2025 | 4 | 2 | J ▲ |
| 2026 | 1 | 0 | D |
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)
1 fine totaling $84,168.
| Date | Type | Amount / length |
|---|---|---|
| Nov 21, 2023 | Fine | $84,168 |
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) | 4.46 | 4.29 | 3.95 | top 37% in Wisconsin; top 24% in the U.S. |
| Registered Nurse hours | 0.84 | 1.01 | 0.69 | bottom 39% in Wisconsin; top 24% in the U.S. |
| Weekend total nurse staffing | 3.46 | 3.84 | 3.50 | bottom 40% in Wisconsin; top 44% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.68 | 0.48 | bottom 11% in Wisconsin; bottom 45% in the U.S. |
| Total nursing staff turnover (%) | 31.1 | 46.9 | 45.8 | top 12% in Wisconsin; top 16% in the U.S. |
| RN turnover (%) | 16.7 | 39.7 | 42.9 | top 13% in Wisconsin; top 9% 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 3.96, RN 0.75, weekend 3.07. Staffing rating: 5/5.
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: 3/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
Government - County
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| County of Walworth | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/19/2006 |
| County of Walworth | Organization | ADP of the SNF | NOT APPLICABLE | 12/31/1973 |
| Johnson, Denise | Individual | Corporate Director | NOT APPLICABLE | 02/24/2020 |
| Johnson, Denise | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/24/2020 |
| Johnson, Denise | Individual | ADP of the SNF | NOT APPLICABLE | 02/24/2020 |
| Monroe, Kenneth | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "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 |
|---|---|---|---|---|---|
| Holton Manor | 0.4 mi | Elkhorn, WI | ★★☆☆☆ | 2/5 | |
| Delavan Health Services | 6.1 mi | Delavan, WI | ★★★★☆ | 4/5 | |
| Williams Bay Health Services | 7.1 mi | Williams Bay, WI | ★☆☆☆☆ | 1/5 | |
| Geneva Lake Manor | 8.7 mi | Lake Geneva, WI | ★☆☆☆☆ | 1/5 | |
| East Troy Manor | 9.6 mi | East Troy, WI | ★★☆☆☆ | 2/5 | |
| Golden Years of Lake Geneva | 10.0 mi | Lake Geneva, WI | ★★★★☆ | 5/5 | |
| Lindengrove Mukwonago | 13.0 mi | Mukwonago, WI | ★★☆☆☆ | 3/5 | |
| Burlington Health and Rehabilitation Center | 14.1 mi | Burlington, WI | ★☆☆☆☆ | 1/5 | |
| Alden Meadow Park HCC | 18.6 mi | Clinton, WI | ★★★☆☆ | 3/5 | |
| Mercy Harvard Hospital Care Center | 19.6 mi | Harvard, IL | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525625.