Cycle 1
Health 2024-11-27 · Fire 2024-11-27
2 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Elkhorn, WI
Holton Manor
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
645 N Church St, Elkhorn, WI
(262) 723-4963
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wisconsin Illinois Senior Housing, Inc.
Operator or chain grouping
Approved since
1994-03-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.92
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.33
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,206
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.56% · Performance 21.81% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.06
Baseline 5.84% · Performance 6.02% · Measure score 6.06 · Achievement 6.06 · Improvement 0
Total nurse turnover
1.69
Baseline 44.44% · Performance 56.79% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Adjusted total nurse staffing
3.25
Baseline 4.05 hours · Performance 4 hours · Measure score 3.25 · Achievement 3.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.21% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 291 · Observed rate 13.06% · Lower 95% interval 10.03% |
| Discharge to community | 55.91% |
50.57%
5.3 pts better
|
No Different than the National Rate · Eligible stays 265 · Observed rate 52.45% · Lower 95% interval 49.29% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.71% |
95.27%
3.4 pts better
|
Numerator 153 · Denominator 155 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 155 |
| Discharge self-care score | 56.35% |
53.69%
2.7 pts better
|
Numerator 71 · Denominator 126 |
| Discharge mobility score | 65.08% |
50.94%
14.1 pts better
|
Numerator 82 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 155 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.02% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 4.52% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 1.5% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 133 |
| Staff flu vaccination coverage | 30.19% |
42%
11.8 pts worse
|
Numerator 48 · Denominator 159 |
| Discharge function score | 61.11% |
56.45%
4.7 pts better
|
Numerator 77 · Denominator 126 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 98.13% |
96.28%
1.8 pts better
|
Numerator 105 · Denominator 107 |
| Resident COVID-19 vaccinations up to date | 36.78% |
25.2%
11.6 pts better
|
Numerator 32 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.6
1.3 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.2%
1.8 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 2.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
5.0%
1.2 pts worse
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.0% · Q3 2.8% · Q4 2.9% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
16.6%
0.8 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 16.7% · Q3 14.3% · Q4 20.0% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
16.7%
1.9 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q3 19.2% · Q4 14.3% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.8% |
21.1%
3.3 pts better
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
17.3%
6.9 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.6% · Q3 3.7% · Q4 12.5% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.0%
1.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
25.5%
3.1 pts better
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 7.0% · Q3 24.8% · Q4 24.2% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.5%
2.2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.7% · Q3 2.2% · Q4 4.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
86.8%
12.7 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.3% · Q4 98.7% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
15.0%
5.7 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 19.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.9% · Q3 1.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
82.2%
17.1 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
22.7%
6.6 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 24.3% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-05-05 · Fire 2022-05-05
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-11-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-10
E · Potential for more than minimal harm
2024-11-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-03
F · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-28
F · Potential for more than minimal harm
2022-05-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-05-23
F · Potential for more than minimal harm
2022-05-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-06
F · Potential for more than minimal harm
2022-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-26
F · Potential for more than minimal harm
2022-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-24
E · Potential for more than minimal harm
2022-05-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-05-24
E · Potential for more than minimal harm
2022-05-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-06
E · Potential for more than minimal harm
2022-05-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-05-06
E · Potential for more than minimal harm
2022-05-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-05-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-05-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-04-20
E · Potential for more than minimal harm
2024-02-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-23
G · Actual harm
2023-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-04
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-04
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-02
Penalties and ownership
What sits behind the stars
Ownership
Carriage Healthcare Companies Inc
Operational/Managerial Control · Organization
Dupont, Lori
Corporate Officer · Individual
Gehler, Miriam
Corporate Director · Individual
Gerlach, Keri
Corporate Director · Individual
Kerwin, Andrew
Corporate Officer · Individual
Kumar, Rajeev
Corporate Director · Individual
Lynn, Nicholas
Corporate Director · Individual
Sherman, Stephanie
W-2 Managing Employee · Individual
Siebel, Robert
Operational/Managerial Control · Individual
Siebel, Robert
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Lakeland Health Care Ctr
Elkhorn, WI
3-star overall rating with 2-star inspections with abuse icon flag with $127,260 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Delavan Health Services
Delavan, WI
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Williams Bay Health Services
Williams Bay, WI
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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