Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holton Manor during CMS and state inspections, most recent first.
Failure to provide timely and effective pressure injury care. A resident admitted with a stage IV wound and high pressure-injury risk developed two new pressure injuries while in the facility, including one linked to wound VAC bridging and another linked to wheelchair rubbing. Another resident with HF, dysphagia, and a G-tube had heel DTIs and a buttock pressure ulcer, but the facility did not complete a comprehensive assessment of the buttock wound for nearly two weeks after it was found, despite existing care plan interventions for offloading, repositioning, and pressure relief.
A resident with dysphagia, dementia, and a history of aspiration pneumonia was supposed to receive a mechanical soft/nectar thick diet with intermittent supervision while eating. Surveyors observed the resident left alone during meals and not properly supervised while eating, including times when a CNA had their back turned or no staff were present. The resident also received the wrong diet with shredded lettuce, choked, coughed up food and phlegm, and was sent to the hospital with aspiration PNA.
The facility failed to maintain an effective infection prevention and control program, with missing monthly infection summaries, no calculated infection rates, no outbreak summaries for respiratory outbreaks, and outdated infection control and pneumococcal vaccine policies. During laundry observations, staff sorted soiled linens with only gloves and no gowns available, and a clean blanket was handled against clothing. A resident with an indwelling Foley had the catheter bag observed on the floor without a protective barrier on two occasions, while staff said the resident was restless and messed with the bag, but the care plan did not reflect those behaviors.
The facility designated the IDON as the IP even though she had not completed specialized IPC training and had no prior IP experience. The facility also did not identify an alternate qualified resource to oversee the IPCP after the previous DON left. Record review showed the facility assessment did not include the IP role or the resources and time needed for IPCP oversight, and the training documentation provided did not show the required specialized IPC topics.
A resident with cerebral palsy, epilepsy, hydrocephalus, bipolar disorder, major depressive disorder, anxiety disorder, and severely impaired cognition had a PASARR Level 1 indicating a Level 2 was required, but the facility could not initially locate the Level 2 in the record. The NHA later provided a document identified as the Level 2, but it did not show when it was completed or submitted, and the facility could not determine the submission date.
A resident with moderate cognitive impairment and care plan directions for 1-assist with dressing/grooming was observed on consecutive days with facial hair and had not been shaved. The CNA said they did not offer or ask to shave the resident and only did not shave the resident because the resident did not ask, while the CNA supervisor stated staff would be expected to ask residents if they want to be shaved.
Failure to Provide Eye Hygiene and ADL Assistance: A resident who was dependent on staff for ADLs and had severe cognitive impairment, contractures, and multiple neurologic and psychiatric diagnoses was observed with significant drainage from both eyes and a sty. Nursing notes documented eye drainage and orders for cleansing, warm compresses, and ophthalmic medication, but the resident stated staff had not washed the eyes, applied a warm compress, or given the ointment when observed by the surveyor.
A resident with severe contractures and another resident with post-stroke hemiparesis did not receive ordered ROM/mobility supports as documented. Staff observed one resident without shoes, palm guards, or rolled washcloths despite care plan directions, and observed the other resident repeatedly without the ordered right AFO while staff gave conflicting information about when it should be worn and whether it was broken. Therapy and nursing staff were unclear on the current orders and documentation for both residents.
A resident with a PEG tube after CABG surgery and traumatic intubation did not have tube placement verified before an LPN attempted to give medication. The LPN listened to bowel sounds, left a gauze drain sponge covering the tube site, and did not check the tube entry point, measure tube length, or aspirate gastric contents before placing water into the syringe barrel; the water did not enter the tube because it was obstructed. Staff interviews showed uncertainty about the facility’s PEG placement protocol, and the record did not show tube-length documentation or visible tube markings for reference.
The facility did not ensure nurse staffing postings showed the total actual hours worked by RN, LPN, and CNA staff for each shift. The posting near the main entrance listed only daily totals, and review of the prior 30 days showed the same issue. The NHA stated the facility only documented hours per day for nurse postings.
Seven CNAs did not complete the required 12 hours of continuing education within their employment year, as confirmed by a review of facility records and acknowledged by the Administrator.
An Agency CNA did not report a resident's overnight chest pain to the nurse on duty, despite the resident's significant cardiac history and cognitive impairment. The omission was discovered by the day shift CNA, who then reported it to the LPN, leading to the resident's assessment and transfer to the hospital. The Agency CNA had not received orientation materials that included specific guidelines for reporting changes in condition.
Failure to Provide Timely and Effective Pressure Injury Care
Penalty
Summary
The facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing. One resident was admitted with a stage IV pressure injury and diagnoses including abscess of bursa, cutaneous abscess of the right hip, paraplegia, and amputation of the left leg below the knee. The resident was assessed as at risk for pressure injuries and had care plan interventions for offloading, repositioning, moisture control, and pressure-redistributing surfaces. Despite these measures being documented, the resident developed two additional pressure injuries while in the facility. For the resident with the stage IV wound, the record showed the initial wound was assessed and treated with wound care, including wound VAC therapy and later dressing changes. However, the surveyor noted that the resident developed a new linear deep tissue injury above the wound VAC site and another new open area related to tape and/or pressure. The surveyor was told one new wound was from wound VAC bridging and the other was from the resident’s power wheelchair rubbing against the skin. The physician order required monitoring the skin around the wound VAC for breakdown every shift, and the surveyor noted no additional information was provided to show the new pressure injuries were unavoidable. A second resident was admitted with heart failure, dysphagia, and a gastrostomy tube, and was assessed as moderate risk for pressure injuries. On admission back from the hospital, the resident had deep tissue injuries to both heels and a stage II pressure ulcer to the buttock. The record showed the buttock wound was discovered on the same day as the skin assessment, but the report states the resident did not have a comprehensive assessment of the right buttock pressure injury from the time it was discovered until later. The resident’s care plan included heel offloading, repositioning, an alternating air mattress, and treatment for the buttock wound, but the deficiency cited that the facility did not ensure timely comprehensive assessment and management of the pressure injury.
Failure to Supervise a Resident During Meals and Serve the Ordered Diet
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with dysphagia, cognitive impairment, and a history of aspiration pneumonia. The resident’s records showed orders and care plan interventions for a Dysphagia 3/mechanical soft diet with nectar thick liquids, intermittent supervision while eating, and close monitoring because the resident tended to eat quickly, take large bites, and become agitated with feeding assistance. The resident’s care plan also noted a history of aspiration risk and prior choking concerns. Survey observations showed the resident was left alone while eating on multiple occasions. During the noon meal, the resident was observed in the dining room with a tray and later was left without facility staff present for 20 minutes while eating. During breakfast on another day, the resident began eating while a CNA was assisting another resident and had the resident’s back turned, and the resident was not supervised for 13 minutes. The speech therapist stated the resident needed supervision during meals, staff should be within eyesight and facing the resident, and the resident should always be supervised while eating because of frequent coughing and difficulty clearing food from the mouth. The resident also received the wrong therapeutic diet during a prior meal and choked on food. Staff reported the resident was served shredded lettuce even though it was not allowed on the resident’s diet. The resident coughed up food and phlegm, had a change in color, and was sent to the hospital, where the discharge diagnosis was aspiration pneumonia. Staff interviews confirmed the resident should have been supervised while eating and that the meal ticket system identified the resident’s required diet, but the wrong food was served and no one caught it before the resident ate.
Infection Control Program and Catheter Care Deficiencies
Penalty
Summary
The facility did not maintain an effective infection prevention and control program or sanitary environment. Survey review found that the facility did not have a system for identifying potential infections using a line list of symptomatic residents, did not report monthly infections with calculated infection rates, and did not provide outbreak summaries for respiratory outbreaks to show investigation of the source of transmission or control of the infection. The infection data that was collected was not used to apply corrective action, and from January 2026 through April 2026 the monthly Infection Summary sheets were missing. The facility’s Infection Control Policy and pneumococcal vaccine policy were undated and not reviewed annually, and the pneumococcal vaccine policy did not reflect current immunizations. During observation of the laundry process, dirty linens and resident personal laundry were being sorted in the laundry room without gowns available for staff. The laundry aide stated that gloves were worn when sorting dirty laundry and that gowns were only used if linens were wet or excessively soiled. The aide also stated that CNAs could sort laundry and that wearing a gown was optional. Survey observation showed the aide handling a freshly laundered blanket in the clean area while the blanket was held against the aide’s clothing. A CNA later stated that when CNAs sort soiled linen bags, they generally wear only gloves and do not wear gowns unless the linens are wet. R23 had an indwelling urinary catheter and diagnoses including hemiplegia and hemiparesis following stroke, aphasia, chronic kidney disease stage 3, obstructive and reflex uropathy, major depressive disorder, benign prostatic hyperplasia with lower urinary tract symptoms, and gross hematuria. Surveyors observed R23’s catheter bag hanging on the side of the bed with the bottom half lying on the floor without a protective barrier on two separate occasions. R23 stated staff cared for the catheter and that R23 did not know how to care for it. Staff stated R23 was restless and tended to mess with the catheter bag, but the care plan did not show revisions to address that behavior or to prevent the bag from ending up on the floor.
Unqualified IP Assigned Without Specialized IPC Training
Penalty
Summary
The facility did not ensure that the staff person designated as the Infection Preventionist (IP) had completed specialized infection prevention and control training before assuming the role. The Interim Director of Nursing (IDON)-B was serving as the facility’s designated IP, but during interview she stated she had not previously worked in the IP role or had similar experience and was still completing certification. Survey review also found that the facility did not designate an alternate qualified resource to oversee the infection prevention and control program (IPCP) while IDON-B was in that role. The facility policy titled Infection Preventionist stated that the facility would designate a qualified individual as IP, ensure the IP had specialized IPC training beyond initial professional training or education, and assign responsibilities including oversight of the IPCP and antibiotic stewardship program. On interview, the Nursing Home Administrator stated the previous DON had been the IP and had overseen the IPCP, but after that person left, the facility was unsure who would oversee the program with IDON-B. The administrator also stated there was an employee with certification, but that employee was not currently overseeing the IPCP or assisting IDON-B in the IP role. Record review showed the facility assessment, reviewed on 2/28/2026, did not identify the IP role and did not include the IP role in staffing hours. The assessment also did not identify the time or resources needed for the IP to carry out IPCP responsibilities. When asked for documentation of IDON-B’s experience or training, the facility provided courses such as antibiotic stewardship, bloodborne pathogens, hand hygiene, infection prevention and control for all staff, and PPE. Survey review noted these courses did not include the specialized IPC training topics required before assuming the IP role, and no additional information was provided.
PASARR Level 2 Screening Not Available or Dated
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed and maintained for 1 resident with a mental disorder and intellectual disability. The resident was admitted with diagnoses including spastic quadriplegic cerebral palsy, epilepsy, hydrocephalus with a ventriculoperitoneal shunt, bipolar disorder, major depressive disorder, and anxiety disorder. The admission MDS documented severely impaired cognition with a BIMS score of 3. The facility’s record contained the PASARR Level 1 screen, which indicated that a Level 2 PASARR screening was required, but the surveyor could not locate a Level 2 PASARR in the resident’s record. During the survey, the surveyor requested the Level 2 PASARR from the facility. The NHA stated the previous admissions staff kept documents in a folder, but no one could locate it and the facility had to reach out to obtain a copy of what had been submitted. The facility later emailed a document identified as the resident’s PASARR Level 2, but the surveyor could not locate a date showing when it was completed or submitted. The NHA stated the facility was not able to determine the submission date, and no additional information was provided.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility did not ensure that a resident’s abilities in ADLs did not diminish unless the resident’s clinical condition made that unavoidable, including assistance with grooming. The resident’s Quarterly MDS documented a BIMS score of 11, indicating moderate cognitive impairment, and assessed the resident as needing partial to moderate staff assistance with personal hygiene. The CNA plan of care and comprehensive care plan both directed staff to provide 1-assist with dressing and grooming because the resident was at risk for self-care deficit related to impaired mobility, CHF exacerbation, oxygen use at bedtime, hard of hearing, confusion, and delusions at times. During observation, the resident was seen in the room with noticeable facial hair and stated they had a razor but did not know why they had not been shaved. On the next day, the resident was again observed with facial hair and still had not been shaved. The CNA stated they did not offer or ask to shave the resident and did not shave the resident because the resident did not ask. The CNA supervisor stated staff would be expected to ask residents if they want to be shaved. The NHA was informed that the resident had not been shaved and that staff had not asked whether the resident wanted to be shaved.
Failure to Provide Eye Hygiene and ADL Assistance
Penalty
Summary
The facility did not ensure that a resident who was dependent on staff for activities of daily living received the necessary services to maintain good grooming and personal hygiene. The resident had diagnoses including spastic quadriplegic cerebral palsy, epilepsy, hydrocephalus, mild cognitive impairment, dysphagia, aphasia, anxiety disorder, major depressive disorder, and bipolar disorder. The resident’s MDS documented severely impaired cognition with a BIMS score of 3, dependence on staff for ADLs, and contractures of the upper and lower limbs with inability to use the hands or feet. The care plan also identified the resident as dependent on staff for grooming, bathing, and personal hygiene. Nursing documentation noted redness and drainage from the resident’s right eye on 4/24/2026, with an NP order to wash both eyes with baby shampoo twice daily for 7 days. On 4/26/2026, nursing documented continued drainage from both eyes, a sty forming on the right eyelid, redness of the upper lid, and orders for artificial tears and warm compresses to the right eye. On 5/5/2026, the resident was observed lying in bed with light yellow stringy drainage covering the right eye and a sty on the right upper inner eyelid. The resident stated that no one had washed the eyes, applied a warm compress, or given the erythromycin ointment, and the surveyor later showed the drainage to the IDON and NHA, who acknowledged that the resident’s eyes should have been cleaned to maintain personal hygiene.
Failure to Provide Ordered ROM and Mobility Supports
Penalty
Summary
The facility did not ensure appropriate care and services were provided to maintain or improve range of motion and mobility for 2 residents with limited ROM. One resident had diagnoses including spastic quadriplegic cerebral palsy, epilepsy, hydrocephalus, mild cognitive impairment, dysphagia, aphasia, anxiety disorder, major depressive disorder, and bipolar disorder, and was assessed as severely cognitively impaired, dependent for ADLs, and contracted in the upper and lower limbs. The resident’s care plan and CNA care card directed staff to use palm protectors or rolled washcloths in both hands and to place shoes on both feet when up in the wheelchair. Survey observations showed the resident sitting in a wheelchair without shoes on both feet, with the right foot crossed over the left foot, and without palm guards or rolled washcloths in either hand. The resident was also observed lying in bed without the hand devices in place. Therapy staff stated the resident should wear shoes on both feet to prevent foot drop and acknowledged the care plan should reflect what the resident currently should have in place. CNA staff stated the resident should have rolled washcloths in both hands and shoes on both feet when up in the wheelchair, but there was uncertainty about whether the resident had palm guards previously and whether any refusal or related documentation had been completed. A second resident had diagnoses including hemiplegia and hemiparesis following stroke affecting the right dominant side, aphasia, and major depressive disorder, and was assessed as needing maximal assistance with ADLs and having right upper and lower extremity impairment. The resident had a physician order for a right AFO due to foot drop, to be worn at all times, with skin checks every shift, and the care plan included monitoring skin under the AFO for breakdown. However, the care plan did not specify exactly when or how often the AFO should be worn. Survey observations showed the resident repeatedly without the right AFO while lying in bed, sleeping, and sitting on the side of the bed, with the brace sitting on a recliner chair instead. The resident stated the brace had not been on and did not recall an orthopedic follow-up. Therapy staff gave conflicting information about when the AFO should be worn, stated they did not monitor it, and reported hearing it might be broken, but no documentation was shown. Nursing staff also expressed uncertainty about the brace’s condition and when it should be worn.
PEG Tube Placement Not Verified Before Medication Attempt
Penalty
Summary
The facility did not ensure that a resident with a gastrostomy tube received appropriate treatment to prevent complications of enteral feeding. The resident had been admitted after CABG surgery with traumatic intubation that resulted in necrotic tissue in the mouth and had a PEG tube placed to receive all nutritional needs. The resident’s tube feeding care plan directed staff to check placement and patency of the feeding tube before each feeding or medication administration, and to check gastric residuals if the resident was not tolerating feedings, the tube position changed, or the aspirate suggested the tube was misplaced. During observation, an LPN prepared to administer medication to the resident and listened to the resident’s abdomen with a stethoscope. A gauze drain sponge was covering the base of the PEG tube and obstructed the view of the tube entry site and how the tube was affixed to the abdomen, and the LPN did not remove the sponge during the procedure. The LPN connected an empty syringe barrel to the PEG tube, opened the valve and clamp, and placed about 30 mL of water into the syringe barrel, but did not check under the sponge, measure the tube length, or attempt to aspirate stomach contents to verify placement. The water did not go into the PEG tube because the tube was obstructed, and another LPN was contacted to help unclog the tube. In interviews, staff were unable to clearly explain the facility’s protocol for checking PEG tube placement. One LPN stated they were not sure how to check placement and looked it up online, then said stomach contents would be pulled back with a syringe. The interim DON stated the protocol was new to them, and the nurse clinical officer stated the policy was to use tube markings and tube length. Surveyor review also noted there was no documentation in the record showing the tube length for staff to reference, and no visible markings were observed on the PEG tube during the observation. The facility later provided its policy and the physician’s order with special instructions for checking placement, but no documentation explained why aspiration was used or how staff would measure the tube when no visible markings were present.
Nurse Staffing Postings Did Not Show Shift Hours
Penalty
Summary
The facility did not ensure that the posted nurse staffing information included the total actual hours worked by RN, LPN, and CNA staff for each shift. During observation on 5/4/2026, the surveyor saw the nurse staff posting near the main entrance and noted that it listed total RN hours, total LPN hours, total medication tech hours, and total CNA hours for the entire day, but did not break the hours down by shift. Review of the nurse staffing postings for the prior 30 days showed the same issue, with no documentation identifying what licensed and unlicensed nursing staff worked each shift. On 5/6/2026, the surveyor informed the NHA that the postings did not include the hours worked by licensed and unlicensed nursing staff per shift, and the NHA stated the facility only documented hours per day for nurse postings.
Failure to Ensure CNAs Complete Required Continuing Education
Penalty
Summary
The facility failed to ensure that seven out of thirty-four reviewed Certified Nurse Aides (CNAs) met the required 12 hours of continuing education within each 12-month employment period, as stipulated by facility policy. The review of continuing education records showed that these CNAs, identified by their dates of hire, had not completed the mandated training hours by their respective employment anniversaries. The facility's policy, dated August 2022, clearly states that all nurse aide personnel must participate in at least 12 hours of continuing education per employment year. During an interview, the Administrator acknowledged awareness that some CNAs had not fulfilled the 12-hour continuing education requirement according to both facility policy and regulatory standards. The deficiency was identified through a review of the facility's records and confirmed by the Administrator, with no mention of corrective actions or follow-up steps in the report.
Failure to Ensure Agency CNA Reported Change in Resident Condition
Penalty
Summary
The facility failed to ensure that an Agency Certified Nurse Aide (CNA) had the necessary competencies to recognize and report a significant change in a resident's condition. Specifically, the Agency CNA did not report to the nurse on duty that a resident had experienced chest pain throughout the night. This omission was discovered when the day shift CNA received a report from the Agency CNA and learned that the chest pain had not been communicated to the nurse. The day shift CNA immediately reported the information to the nurse coming on duty. The resident involved had a history of severe cognitive impairment and multiple cardiac-related diagnoses, including a history of coronary artery bypass grafts and atherosclerotic heart disease. Upon assessment by the nurse, the resident reported ongoing chest pain, shortness of breath, and weakness in the arms. Vital signs indicated low blood pressure and decreased oxygen saturation. The nurse notified the physician and the resident was subsequently sent to the hospital for further evaluation. Review of facility policies and orientation materials revealed that the Agency CNA had received an orientation packet, but it did not include specific guidelines on when to report changes in condition to nursing staff, such as those outlined in the facility's Physician Notification Practice Guidelines. The omission of this critical information contributed to the Agency CNA's failure to report the resident's chest pain to the nurse on duty.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Elkhorn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeland Health Care Ctr | 0.4 mi | ★★★★★ | 7 | 1 |
| Delavan Health Services | 5.8 mi | ★★★★★ | 0 | 0 |
| Williams Bay Health Services | 7.1 mi | ★★★★★ | 36 | 1 |
| Geneva Lake Manor | 8.9 mi | ★★★★★ | 9 | 1 |
| East Troy Manor | 9.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.