Shorehaven Hlth & Rehab Ctr
1305 W Wisconsin Ave, Oconomowoc, WI 53066 · Waukesha County · (262) 567-8341
88 certified beds, about 73 residents a day · Non profit - Corporation · Medicare and Medicaid since 1995
CMS high performing icon Part of a continuing care retirement community Certified for Medicaid Certified for Medicare
Overall
5 of 5
Health inspections
4 of 5
Staffing
5 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 525560 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 11, 2025, inspectors cited 3 health deficiencies (the Wisconsin average is 9.5, the national average 9.2).
Of 10 health citations since November 2022, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.41 hours per resident per day, against 4.21 across Wisconsin and 3.86 nationally. Registered nurses accounted for 1.33 of those hours.
38.8% of nursing staff left within the year CMS measured (Wisconsin average 46.9%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
311/22
102/24
106/24
306/25
203/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
6D
1E
1F
Potential for minimal harm
0A
0B
0C
March 5, 2026Complaint inspection · 2 citations
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R1 and R3) of 2 residents with allegations of abuse were reported to the State Agency and one or more law enforcement entities. *On 2/9/26, R3 alleged Certified Nursing Assistant (CNA)-D pushed R3 against the wall and slapped R3 on the face with a wet rag. The facility did not report the allegation of abuse within 2 hours to the State Agency as required and the facility did not report the allegation of abuse to law enforcement as required. *On 1/25/26, R1 and R2 were involved in a resident-to-resident altercation. R1's allegation of abuse was not submitted to the State Agency timely and law enforcement was not notified.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R3) of 3 residents reviewed for allegation of abuse were provided a thorough investigation after the alleged violation. The facility's self-report dated 2/9/26 indicated Certified Nursing Assistant (CNA)-D pushed R3 against the wall and slapped R3 on the face with a wet rag. CNA-D continued to work with other residents after abuse allegations on 2/9/26.
June 11, 2025Standard inspection · 3 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteDishwasher Temperatures: The 2022 Wisconsin Food Code documents at 4-501.110 .Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74° C (165° F); (2) For a stationary rack, dual temperature machine, 66° C (150° F); (3) For a single tank, conveyor, dual temperature machine, 71° C (160°F); or (4) For a multitank, conveyor, multitemperature machine, 66° C (150° F). The facility's Maintenance, Sanitation and Safety policy, revised 1/2018, indicates: .Sanitation: [...]
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 2 sampled residents received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. Neither R9 or R9's representative were provided with a written bed hold notice that included the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility when R9 was transferred to the hospital on 6/6/25.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R1) of 2 sampled residents. The facility did not ensure R1's oxygen orders were consistently followed. Findings Include: The facility's Oxygen Administration Concentrators policy, revised 4/19/25, indicates: .Procedure: .C. Press power switch on position and adjust oxygen flow .D. Read the center of the ball with the meter at eye level. If unable to obtain the proper flow rate, check for kinks in the tubing or loose connections. From 6/9/25 to 6/11/25, Surveyor reviewed R1's medical record. [...]
June 25, 2024Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff applied a foot pedal to a wheelchair during transport of the resident to prevent an accident for 1 of 3 sampled residents (R1) reviewed for accidents.
February 22, 2024Standard inspection · 1 citation
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview, the facility did not ensure food was prepared safely and temperatures taken in 5 of 5 household kitchens. This deficient practice has the potential to affect 80 of the 82 residents currently residing in the facility who receive their meals from the household kitchens. * End of service temperature checks were not being completed 4 times a month on AM and PM shift. * Temperatures were not being taken for breakfast food cooked in the individual household kitchens.
November 14, 2022Standard inspection · 3 citations
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R9) of 3 Residents reviewed for pressure injuries. * R9 was admitted to the facility on [DATE] with diagnoses which included a right hip fracture. The admission body check documents a 3.0 x 1.8 cm (centimeter) purple area that is not open potentially indicating the presence of a DTI (deep tissue injury). The wound assessment 8/9/22 documents a Stage 2 PI with 90% slough & 10% epithelial tissue. R9's pressure injury was not staged correctly as a Stage 2 pressure injury does not include slough. The 8/17/22 wound assessment continues to stage R9's pressure injury as a Stage 2 with 100% granulation tissue. [...]
- D Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility did not refer 1 (R62) of 1 residents reviewed for a Level II PASARR (Preadmission Screen and Resident Review) whom was found to have a newly diagnosed mental illness and prescribed psychotropic medication used to treat the symptoms of the mental illness. On 4/13/2022 R62 was diagnosed with Generalized Anxiety Disorder and started to receive Depakote and the Zoloft. On 5/11/2022 R62 was diagnosed with Psychotic disorder with delusions due to known physiological condition. On 5/11/2022 R62 began receiving Abilify to treat symptoms. On 7/7/2022 R62 was diagnosed with Alzheimer's disease with late onset and on 10/19/2022 R62 was diagnosed with Dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbances. [...]
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the Facility did not ensure that 1 (R29) out of 5 residents reviewed for unnecessary medication received behavior monitoring based on their targeted behaviors. R29 was administered Lexapro 10 mg (milligrams) without behavior monitoring completed for the continued use of this medication.
Fire safety inspections
8 fire safety citations on file: 2 on June 11, 2025, 4 on February 22, 2024, 2 on November 14, 2022.
Every fire safety citation8 citations
- D Provide properly protected cooking facilities.
- D Have simulated fire drills held at unexpected times.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
- D Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- C Provide a written emergency evacuation plan.
- F Provide properly protected cooking facilities.
- D Have properly located and lighted "Exit" signs.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| June 25, 2024 | Payment Denial | 13 days from July 27, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Wisconsin | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.41 | 4.21 | 3.86 |
| Registered nurses | 1.33 | 0.99 | 0.69 |
| All nursing staff on weekends | 4.87 | 3.77 | 3.42 |
| Nurse aides | 3.34 | ||
| Licensed practical nurses | 0.74 | ||
| Nursing staff turnover (share who left in a year) | 38.8% | 46.9% | 45.8% |
| Registered nurse turnover | 13.6% | 39.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.73 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.62 on weekdays and 4.87 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.07 in April to June 2025 to 5.41 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.41 | 1.33 | 5.62 | 4.87 | 0.8% | 0 of 90 | 73 |
| Oct to Dec 2025 | 5.23 | 1.21 | 5.42 | 4.73 | 1.1% | 0 of 92 | 76 |
| Jul to Sep 2025 | 5.04 | 1.17 | 5.25 | 4.52 | 0.8% | 0 of 92 | 80 |
| Apr to Jun 2025 | 5.07 | 1.22 | 5.30 | 4.49 | 0.0% | 0 of 91 | 77 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Wisconsin, Jan to Mar 2026 | 4.19 | 0.95 | 4.36 | 3.74 | 8.8% | 0.3% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Wisconsin | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.3 | 16.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.8 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.0 | 2.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.8 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.8 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 26.5 | 18.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 0.3 | 5.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.6 | 15.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.7 | 23.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 6.2 | 15.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 2.3 | 1.8 |
Owners and operators
Legal business name: LUTHERAN HOMES OF OCONOMOWOC INC..
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bergin, Scott | W-2 managing employee | Individual | 06/10/2024 | |
| Boray, Johathan | Corporate director | Individual | 10/20/2022 | |
| Boyer-Ruan, Beth | Corporate director | Individual | 10/19/2023 | |
| Buscemi, Alfonso | Corporate director | Individual | 10/17/2024 | |
| Lammers, Joel | Corporate director | Individual | 10/24/2021 | |
| Lentz, William | Corporate director | Individual | 10/21/2021 | |
| Mayer, Roger | Corporate director | Individual | 10/20/2022 | |
| Miller, Mary | Corporate director | Individual | 10/21/2021 | |
| O'Malley, Mary | Corporate director | Individual | 10/24/2019 | |
| Ratzel, Mary Lee | Corporate director | Individual | 04/01/2015 | |
| Sokop, Mary | Corporate director | Individual | 10/24/2018 | |
| Bergin, Scott | Corporate officer | Individual | 06/10/2024 | |
| Holland, Philip | Corporate officer | Individual | 10/21/2021 | |
| Cooper, William | Operational/managerial control | Individual | 11/27/2024 | |
| Dahlke, Dale | Operational/managerial control | Individual | 01/08/2018 | |
| Karls, Emily | Operational/managerial control | Individual | 11/26/2024 | |
| Polinske, Bryan | Operational/managerial control | Individual | 06/30/2018 | |
| Cooper, William | Adp of the SNF | Individual | 12/05/2024 | |
| Karls, Emily | Adp of the SNF | Individual | 12/05/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on June 11, 2025: "Provide safe and appropriate respiratory care for a resident when needed."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 2 problems in this area, most recently on March 5, 2026: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 2 problems in this area, most recently on June 11, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 1 problem in this area, most recently on June 11, 2025: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
Other nursing homes nearby
- Lake Country Health Services Oconomowoc, 4.7 mi · 2 of 5 stars · 42 citations
- Masonic Center for Health & Rehab Inc. Dousman, 7.3 mi · 5 of 5 stars · 3 citations
- Watertown Health Care Center Watertown, 10.6 mi · 1 of 5 stars · 98 citations
- Marquardt Memorial Manor Watertown, 11 mi · 2 of 5 stars · 46 citations
- Lindengrove Waukesha Waukesha, 14.5 mi · 1 of 5 stars · 47 citations
- Avina of Pewaukee Waukesha, 14.6 mi · 1 of 5 stars · 55 citations
- Complete Care at Kensington Waukesha, 15.7 mi · 1 of 5 stars · 32 citations
- Aria of Waukesha Waukesha, 16.8 mi · 1 of 5 stars · 25 citations
Wisconsin contacts for a concern about a nursing home
These are the official offices in Wisconsin. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Wisconsin Department of Health Services, Division of Quality Assurance, Nursing Homes, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Wisconsin Board on Aging and Long Term Care, Ombudsman Program, 1-800-815-0015. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Wisconsin DHS Provider Search (Survey History), where Wisconsin publishes its own records on licensed homes.
Common questions
- What is Shorehaven Hlth & Rehab Ctr's Medicare star rating?
- CMS rates Shorehaven Hlth & Rehab Ctr 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Shorehaven Hlth & Rehab Ctr get at its last inspection?
- 3 health deficiencies at the standard inspection on June 11, 2025. The Wisconsin average is 9.5.
- Has Shorehaven Hlth & Rehab Ctr been fined?
- CMS lists no fines in the last three years.
- Does Shorehaven Hlth & Rehab Ctr accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Shorehaven Hlth & Rehab Ctr?
- CMS lists 19 owners and managers. Legal business name: LUTHERAN HOMES OF OCONOMOWOC INC..
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.