Cycle 1
Health 2025-06-11 · Fire 2025-06-11
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Oconomowoc, WI
Shorehaven Hlth & Rehab Ctr
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1305 W Wisconsin Ave, Oconomowoc, WI
(262) 567-8341
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
88
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-02-01
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
1.17
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.15
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.04
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.52
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
5.14
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
394
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.75
Composite VBP score used to determine payment impact.
Payment multiplier
1.0227
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.64% · Performance 16.50% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
6.98
Baseline 6.27% · Performance 5.75% · Measure score 6.98 · Achievement 6.98 · Improvement 3.59
Total nurse turnover
5.33
Baseline 34.43% · Performance 41.91% · Measure score 5.33 · Achievement 5.33 · Improvement 0
Adjusted total nurse staffing
6
Baseline 4.72 hours · Performance 4.78 hours · Measure score 6 · Achievement 6 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.47% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 197 · Observed rate 4.57% · Lower 95% interval 5.95% |
| Discharge to community | 55.98% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 55.11% · Lower 95% interval 49.07% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 105 · Denominator 105 |
| Falls with major injury | 0.95% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 105 |
| Discharge self-care score | 57.89% |
53.69%
4.2 pts better
|
Numerator 55 · Denominator 95 |
| Discharge mobility score | 44.21% |
50.94%
6.7 pts worse
|
Numerator 42 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 1.9% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 105 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | 5.75% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 2.08% · Lower 95% interval 3.09% |
| Staff COVID-19 vaccination coverage | 4.58% |
8.2%
3.6 pts worse
|
Numerator 12 · Denominator 262 |
| Staff flu vaccination coverage | 47.62% |
42%
5.6 pts better
|
Numerator 220 · Denominator 462 |
| Discharge function score | 58.95% |
56.45%
2.5 pts better
|
Numerator 56 · Denominator 95 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 26.79% |
25.2%
1.6 pts better
|
Numerator 15 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
95.7%
1.6 pts worse
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 95.7% · Q3 96.9% · Q4 94.1% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.0%
3.7 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.5% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
5.0%
3 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.4% · Q4 1.6% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.9%
2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 1.9% · Q4 5.4% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
16.6%
0.6 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 15.7% · Q3 16.4% · Q4 12.5% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
16.7%
0.9 pts better
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 20.5% · Q3 10.9% · Q4 8.0% · 4Q avg 15.8% · 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 | 23.6% |
21.1%
2.5 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
17.3%
7.5 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 7.3% · Q3 8.9% · Q4 6.4% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
3.0%
1.5 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 9.0% · Q3 1.6% · Q4 4.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.1% |
25.5%
10.6 pts worse
|
19.8%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 33.8% · Q3 27.3% · Q4 44.3% · 4Q avg 36.1% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.5%
4.4 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.4% |
86.8%
6.4 pts worse
|
81.7%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.0% · Q2 76.2% · Q3 85.7% · Q4 87.6% · 4Q avg 80.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
15.0%
2 pts better
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 11.0% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.9% |
82.2%
20.3 pts worse
|
79.7%
17.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
22.7%
1.2 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 17.6% · Expected 17.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-11-14 · Fire 2022-11-14
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-06-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-26
E · Potential for more than minimal harm
2024-02-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-12
E · Potential for more than minimal harm
2024-02-22
K791 · Miscellaneous Deficiencies
Fire Safety
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.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-22
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-02-23
C · Minimal harm
2024-02-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-20
F · Potential for more than minimal harm
2022-11-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-03
D · Potential for more than minimal harm
2022-11-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-11
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 2025-07-08
D · Potential for more than minimal harm
2025-06-11
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-06-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-08
G · Actual harm
2024-06-25
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 2024-08-09
E · Potential for more than minimal harm
2024-02-22
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 2024-03-14
G · Actual harm
2022-11-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-11-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-04
Penalties and ownership
What sits behind the stars
$0
2024-06-25
Payment Denial
Payment Denial · denial start 2024-07-27 · 13 days
13 day denial
Ownership
Bergin, Scott
Corporate Officer · Individual
Bergin, Scott
W-2 Managing Employee · Individual
Boray, Johathan
Corporate Director · Individual
Boyer-Ruan, Beth
Corporate Director · Individual
Buscemi, Alfonso
Corporate Director · Individual
Cooper, William
Operational/Managerial Control · Individual
Dahlke, Dale
Operational/Managerial Control · Individual
Holland, Philip
Corporate Officer · Individual
Karls, Emily
Operational/Managerial Control · Individual
Lammers, Joel
Corporate Director · Individual
Lentz, William
Corporate Director · Individual
Mayer, Roger
Corporate Director · Individual
Miller, Mary
Corporate Director · Individual
O'malley, Mary
Corporate Director · Individual
Polinske, Bryan
Operational/Managerial Control · Individual
Ratzel, Mary Lee
Corporate Director · Individual
Sokop, Mary
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Lake Country Health Services
Oconomowoc, WI
2-star overall rating with 2-star inspections with $185,950 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Masonic Center For Health & Rehab Inc
Dousman, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Watertown Health Care Center
Watertown, WI
1-star overall rating with 1-star inspections with $276,120 in total fines with 20 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
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