Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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 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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 87 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | — | 5 | 0 |
| Delavan Health Services | 5.8 mi | — | 0 | 0 |
| Williams Bay Health Services | 7.1 mi | — | 1 | 0 |
| 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.