Report
TheVardellReport
Holton Manor
Skilled nursing facility and nursing facility
645 N Church St
Elkhorn, WI 53121
Report
← Holton Manor, free profile
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The Vardell Report.Holton Manor
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Elkhorn, WI
- Record Period
- 2023–2026
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 6 inspections from August 2023 to May 2026, state surveyors documented 17 findings at Holton Manor; 17 have a recorded correction; CMS lists no enforcement action in the window.
- Inspections
- 6
- 2023–2026, standard and complaint
- Findings
- 17
- Deficiencies cited by state inspectors
- Corrected
- 17
- Of 17 findings, with a recorded correction date
- Penalties
- 0
- No fines or payment denials in the window
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 4 | 1 |
| 2024 | 2 | 1 | 0 |
| 2025 | 1 | 2 | 0 |
| 2026 | 1 | 10 | 2 |
What the Record Shows
- 17 of 17 findings have a recorded correction date.
- CMS lists no fines or payment denials in this window.
- 3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, May 6, 2026, recorded 10 findings (most serious: Level G).
What to Ask About
Report at a Glance
- Facility
- Holton Manor
- Address
- 645 N Church St, Elkhorn, WI 53121
- CMS Certification Number
- 525541
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 60
- Ownership
- Non profit - Corporation
- Record Window
- August 24, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
10 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jun 25, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected May 30, 2026
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jun 25, 2026
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected May 30, 2026
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected May 30, 2026
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected May 30, 2026
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 30, 2026
- F688Provide 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.Level DNo actual harm, potential for moreCorrected May 30, 2026
- F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected May 30, 2026
- F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected May 30, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Apr 20, 2025
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Apr 20, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Feb 23, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
4 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Nov 2, 2023
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Nov 2, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 2, 2023
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 2, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in February 2024 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242526F689 across all 6 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level G.
- 02
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 03
Has the home been fined or had payments denied before this record begins?
CMS lists no fines or payment denials in this window. The record starts August 24, 2023; anything earlier is not in it.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wisconsin state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Aug 24, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Oct 4, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Feb 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Nov 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection Mar 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wisconsin state survey agency
Inspection May 6, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 525541
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowAugust 24, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before August 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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