Cycle 1
Health 2024-08-29 · Fire 2024-08-29
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Elkhorn, WI
Lakeland Health Care Ctr
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
1922 Cty Rd Nn, Elkhorn, WI
(262) 741-3600
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.75
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
735
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0190
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.57
Baseline 20.10% · Performance 19.78% · Measure score 3.57 · Achievement 3.57 · Improvement 0.55
Healthcare-associated infections
7.33
Baseline 6.14% · Performance 5.64% · Measure score 7.33 · Achievement 7.33 · Improvement 3.85
Total nurse turnover
8.24
Baseline 34.78% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 4.32
Adjusted total nurse staffing
6.68
Baseline 4.22 hours · Performance 4.98 hours · Measure score 6.68 · Achievement 6.68 · Improvement 4.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.92% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 12.41% · Lower 95% interval 8.64% |
| Discharge to community | 43.71% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 40.16% · Lower 95% interval 37.05% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 69 · Denominator 69 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 69 |
| Discharge self-care score | 56.9% |
53.69%
3.2 pts better
|
Numerator 33 · Denominator 58 |
| Discharge mobility score | 36.21% |
50.94%
14.7 pts worse
|
Numerator 21 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 2.05% |
| Healthcare-associated infections requiring hospitalization | 5.64% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 1.39% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 7.88% |
8.2%
0.3 pts worse
|
Numerator 16 · Denominator 203 |
| Staff flu vaccination coverage | 53.28% |
42%
11.3 pts better
|
Numerator 138 · Denominator 259 |
| Discharge function score | 53.45% |
56.45%
3 pts worse
|
Numerator 31 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.5% |
25.2%
17.7 pts worse
|
Numerator 3 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.4 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
2.2
1.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
95.7%
3.9 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 99.6% |
| 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 | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.3% · Q3 1.4% · Q4 1.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 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 lose too much weight | 0.9% |
4.9%
4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
16.6%
3 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.5% · Q3 15.0% · Q4 14.8% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
16.7%
5.7 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.5% · Q3 23.1% · Q4 18.2% · 4Q avg 22.4% · 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 | 27.4% |
21.1%
6.3 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 28.2% · Q3 21.8% · Q4 28.6% · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
17.3%
2.1 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 13.7% · Q3 24.1% · Q4 22.2% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.3%
1.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
3.0%
2.3 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.9% · Q3 5.9% · Q4 5.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
25.5%
2.4 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 28.0% · Q3 22.6% · Q4 29.2% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.5%
4.2 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 1.1% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
86.8%
12.9 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
15.0%
3.4 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.3% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 3.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.2%
17.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
22.7%
1 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 16.7% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-07 · Fire 2023-06-07
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-02-24 · Fire 2022-02-24
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-29
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-08-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
E · Potential for more than minimal harm
2024-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-20
C · Minimal harm
2024-08-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-18
C · Minimal harm
2024-08-29
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-18
C · Minimal harm
2024-08-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-19
F · Potential for more than minimal harm
2023-06-07
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-07
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-06-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-20
F · Potential for more than minimal harm
2023-06-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-06-07
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-06-23
C · Minimal harm
2023-06-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-19
F · Potential for more than minimal harm
2022-02-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-24
F · Potential for more than minimal harm
2022-02-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-03-24
F · Potential for more than minimal harm
2022-02-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-02-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-02-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-24
F · Potential for more than minimal harm
2022-02-24
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-02-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-16
E · Potential for more than minimal harm
2022-02-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-03-11
E · Potential for more than minimal harm
2022-02-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-11
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-25
G · Actual harm
2025-09-02
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-07-07
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 2025-07-29
D · Potential for more than minimal harm
2025-07-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-29
D · Potential for more than minimal harm
2024-08-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
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 2024-09-30
D · Potential for more than minimal harm
2024-08-29
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 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-30
K · Immediate jeopardy
2023-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-15
J · Immediate jeopardy
2023-11-21
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-21
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 2023-12-15
E · Potential for more than minimal harm
2023-11-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-06-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-06-07
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 2023-06-26
D · Potential for more than minimal harm
2023-06-07
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-26
G · Actual harm
2022-02-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-24
F · Potential for more than minimal harm
2022-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-24
E · Potential for more than minimal harm
2022-02-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-03-24
E · Potential for more than minimal harm
2022-02-24
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-02-24
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-02-24
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-03-24
D · Potential for more than minimal harm
2022-02-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-03-24
C · Minimal harm
2022-02-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-03-24
Penalties and ownership
What sits behind the stars
$127,260
2023-11-21
Fine
Fine · fine $127,260
Fine
Ownership
County Of Walworth
5% Or Greater Direct Ownership Interest · Organization
Johnson, Denise
Operational/Managerial Control · Individual
Johnson, Denise
Corporate Director · Individual
Monroe, Kenneth
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Holton Manor
Elkhorn, WI
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 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
Jump out