Map showing the location of LAKELAND HEALTH CARE CTR in ELKHORN, Wisconsin
1922 CTY RD NN, ELKHORN, WI, 53121

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinAbove only 42% of peers321 rated homes · average 3.0★
  • Walworth CountyAbove only 33% of peers7 rated homes · average 3.0★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs WI avg
  • StaffingCan add or remove a star5★+1.3 vs WI avg
  • Quality measuresCan add or remove a star4★+0.9 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 71% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 58% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.40hrsAbove 65% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.75hrsAbove only 27% of peersWI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better24%Top 4%WI avg48%RN turnover27%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$127,260Above only 12% of peersWI avg$41,875Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
28citations
7inspection dates
2actual harm (G–I)
3immediate jeopardy (J–L)
Sep 2, 2025most recent

Citations by monthFeb 2022 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 2, 20252 citationsCycle 1worst J · immediate jeopardy
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Aug 25, 2025
  2. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareG · isolatedCorrected Sep 17, 2025
Jul 7, 20252 citationsCycle 1worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jul 29, 2025
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 29, 2025
Aug 29, 20246 citationsCycle 1worst D · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Sep 30, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Sep 30, 2024
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 30, 2024
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 30, 2024
  5. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 30, 2024
  6. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 30, 2024
Nov 21, 20234 citationsCycle 3worst K · immediate jeopardy$127,260
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 15, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Dec 15, 2023
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 15, 2023
  4. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareJ · isolatedCorrected Dec 15, 2023
Aug 8, 20231 citationCycle 3worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 18, 2023
Jun 7, 20235 citationsCycle 2worst E · no actual harm
  1. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Jun 26, 2023
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jun 26, 2023
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 26, 2023
  4. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jun 23, 2023
  5. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 26, 2023
Feb 24, 20228 citationsCycle 3worst G · actual harm
  1. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Mar 24, 2022
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 24, 2022
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 24, 2022
  4. 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.Quality of Life and CareD · isolatedCorrected Mar 24, 2022
  5. F700Try 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.Quality of Life and CareD · isolatedCorrected Mar 24, 2022
  6. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesC · widespreadCorrected Mar 24, 2022
  7. F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationE · patternCorrected Mar 24, 2022
  8. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 24, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.40hrsAbove 65% of peers+0.21 vs WI avg
  • Registered nursesRN hours only0.75hrsAbove only 27% of peers−0.21 vs WI avg
  • Licensed practical nursesLPN hours0.68hrs
  • Nurse aidesCNA hours2.97hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.75hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better24%Top 4%WI avg 48%
  • RN turnoverRegistered nurses only27%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy90 certified beds · ~85 residents a day95%Top 7%WI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $127,260In fines
  • 1Fine
  • 0Payment denials
  • $41,875WI avg in fines
Above only 12% of peersFewer fines than 12% of rated homes in Wisconsin

Actions on record

  1. Nov 21, 2023Civil money penalty$127,260

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Independent
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • County of Walworth
Operational or managerial control
  • Denise Johnson
Corporate directors
  • Denise Johnson
Corporate officers
  • Kenneth Monroe

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525625 · 1922 CTY RD NN, ELKHORN, WI, 53121.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Walworth County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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