Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shorehaven Hlth & Rehab Ctr during CMS and state inspections, most recent first.
The facility failed to follow required abuse reporting procedures in two separate incidents. In one case, a resident with dementia and visual impairment alleged that a CNA pushed and slapped the resident during cares; the CNA informed an RN, who assessed the resident but did not promptly notify administration, and the allegation was not reported to the State Agency within the required 2-hour window or to law enforcement. In another case, two residents were involved in a hair-pulling and wheelchair-shaking altercation in a common area; staff intervened and an RN found no injuries, but the initial abuse report to the State Agency was submitted many hours late, and law enforcement was not contacted. These actions and inactions resulted in noncompliance with regulatory requirements for timely reporting of suspected abuse and notification of law enforcement.
A resident with vascular dementia, anxiety, weakness, and legal blindness, who required extensive assistance with mobility and toileting, alleged that a CNA pushed them against a wall and a Sara Steady bar and slapped their face multiple times with a wet rag during cares. An RN assessed the resident, who reported pain but showed no visible injury, and the CNA reported she did not leave the room immediately because the resident was attempting to self-transfer. Despite a facility policy requiring immediate removal and suspension of any staff member suspected of abuse during an investigation, the CNA continued working with other residents for the remainder of the shift, and the RN did not clearly communicate the situation as an abuse allegation to supervisory staff at the time, resulting in a failure to follow the facility’s abuse investigation and resident protection procedures.
Surveyors found that staff failed to consistently monitor and document dishwasher, food, and storage temperatures, did not properly label or date food items, and did not always use hair restraints or follow safe cooling protocols. Incomplete logs and unclear procedures were observed in both the main kitchen and unit kitchens, with staff interviews confirming gaps in knowledge and practice regarding food safety standards.
A resident with moderate cognitive impairment and an activated POA for Healthcare was transferred to the hospital without receiving written notification of the bed hold policy, reserve bed payment policy, or right to return, as required. Staff interviews confirmed that while the policy is reviewed at admission, the bed hold letter at transfer lacked key information and was not directly discussed with the resident or representative.
A resident with a history of neurological and spinal conditions, who required BiPAP with 4L oxygen per physician orders, was observed using the BiPAP machine with the oxygen concentrator set below the ordered amount or not turned on at all. An LPN confirmed the concentrator was set at 1.5L instead of 4L, and the DON acknowledged the concentrator should have matched the physician's order.
A resident with a history of hemiplegia and hemiparesis was transported without a right foot pedal on their wheelchair, resulting in their foot being placed under the wheelchair and causing pain. The incident was witnessed by staff, and an x-ray later revealed fractures in the resident's ankle area. The facility's investigation could not determine if the fractures were directly caused by the incident.
Failure to Timely Report Abuse Allegations and Notify Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse to the State Agency and to notify law enforcement, as required by regulation and by the facility’s own abuse policy. The facility’s policy on freedom from abuse, neglect, exploitation, and misappropriation directs that suspected abuse be immediately reported to a nursing supervisor, who must then notify the DON and NHA, and that the NHA report to the state within the allowed time frame and involve other regulatory authorities, including law enforcement, as needed. In the case of one resident, the facility did not report an allegation of staff-to-resident physical abuse to the State Agency within 2 hours and did not notify law enforcement at all. In a separate incident involving a resident-to-resident altercation, the facility submitted the initial abuse report to the State Agency more than 19 hours after the event and again did not contact law enforcement. In the first incident, a resident with vascular dementia, generalized anxiety disorder, weakness, legal blindness, and moderate cognitive impairment (BIMS score of 9) alleged that a CNA pushed the resident against the wall and the bar of a Sara Steady device and slapped the resident in the face multiple times with a wet rag during cares around 12:30 a.m. The CNA reported that the resident alleged she had hit the resident and that she attempted to get the nurse but did not leave the resident due to the resident attempting to self-transfer; she then assisted the resident back to bed and reported the allegation to the RN. The RN assessed the resident, documented that the resident reported pain but had no visible swelling, redness, or bruising, and continued to provide care for the resident for the remainder of the shift while the CNA continued working her shift, though no longer caring for that resident. The RN did not notify the NHA or DON of the allegation during the shift and stated she viewed the situation as confusion rather than an abuse allegation, and she acknowledged she should have removed the CNA and reported the allegation to administration immediately. Law enforcement was not contacted, and the facility did not report the allegation to the State Agency within the required 2-hour timeframe. In the second incident, a cognitively intact resident (BIMS score of 14) was seated at a dinner table across from another resident with Alzheimer’s disease, dementia with psychotic disturbance, and severe cognitive impairment (BIMS score of 4). During the meal, the cognitively impaired resident moved to the opposite side of the table, pulled the other resident’s hair, and shook the resident’s wheelchair. Staff present in the room intervened immediately and separated the residents, and an RN assessed the resident who was grabbed and found no injuries. The incident was documented as an allegation of abuse, but the initial Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, Misconduct Incident Report was not submitted to the State Agency until the following morning at 9:10 a.m., approximately 19 hours and 10 minutes after the incident, exceeding the 2-hour reporting requirement. The facility did not contact law enforcement regarding this resident-to-resident altercation, and the DON confirmed that police were not notified because no injury occurred.
Failure to Remove Accused Staff and Thoroughly Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough abuse investigation and to follow its own abuse policy after a resident alleged physical abuse by a CNA. The facility’s F600 policy requires that when abuse is observed or suspected, the resident is made safe, the incident is immediately reported to a supervisor, the DON and NHA are notified, and the accused staff member is removed from the premises and suspended from work until the investigation is concluded. The policy also calls for interviews of the accused, the resident, witnesses, and others as needed, and specifies that when a staff member is suspected, they will be sent home and not allowed to return to work unless the investigation demonstrates they are not guilty of abuse or misappropriation. The resident involved is an older adult with vascular dementia, generalized anxiety disorder, weakness, and legal blindness, with a BIMS score of 9 indicating moderate cognitive impairment. The resident requires partial to maximal assistance with mobility and is dependent on staff for toileting hygiene and transfers, with frequent urinary incontinence and constant bowel incontinence. According to the facility’s self-report, at approximately 12:30 AM, a CNA was performing cares when the resident alleged the CNA pushed them against the wall and the bar of a Sara Steady and slapped them in the face six times with a wet rag. An RN documented that the resident reported pain but showed no swelling, redness, or bruising on assessment. The CNA reported that the resident alleged the CNA hit them, and the CNA stated she attempted to get the nurse but did not leave the room because the resident was attempting to self-transfer. Despite the facility’s policy requiring immediate removal and suspension of the accused staff member during an abuse investigation, the CNA continued to work with other residents after the abuse allegation during that same shift, although she did not continue to care for the alleging resident. The RN who was notified of the allegation continued cares for the resident for the remainder of the shift and reported the incident to the day shift nurse and the night shift supervisor, but stated she was not clear with the night shift supervisor that it was an allegation of abuse and initially viewed it as confusion rather than abuse. The Director of Social Services later learned of the allegation during morning rounds when the resident reported being hit with a rag and then notified the NHA and DON. The surveyor confirmed that the CNA continued to work after the allegation and the DON acknowledged concerns about this, demonstrating that the facility did not fully implement its abuse policy to protect residents during the investigation.
Widespread Food Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including failures in monitoring and documenting critical food safety practices. Dishwashers on the units were not consistently monitored for appropriate wash and rinse temperatures, with numerous missing entries on temperature logs for both the AM and PM shifts. Staff interviews confirmed that logs were incomplete and that there was confusion regarding the proper procedures for recording and maintaining these records. Additionally, meal service temperature logs for cooked food and hot/cold holding were incomplete, with several days lacking documentation of required temperatures for breakfast, lunch, and supper. Staff acknowledged that they were trained to take and record these temperatures but admitted that documentation was not consistently performed. Refrigerator and freezer temperature logs were also found to be incomplete or missing for several days and units, with some months lacking any documentation at all. Staff interviews revealed that daily monitoring and documentation were expected but not reliably carried out. Furthermore, the facility failed to ensure that time/temperature control foods were properly labeled with open and use-by dates, and expired or undated food items were found in dry storage, coolers, and freezers across the main kitchen and unit kitchens. Staff, including the Director of Dining, were unclear about the facility's dating policy and use-by dates, and some staff were unaware of the requirements outlined in the Wisconsin Food Code. Additional deficiencies included inconsistent use of hair restraints by staff while preparing and serving food, failure to follow safe food cooling protocols, and lack of awareness regarding temperature requirements for sanitizing solutions. Observations showed staff with unrestrained hair in food preparation areas and food items being cooled without proper monitoring or documentation. The facility did not use food cooling logs, and staff did not measure or track the cooling process for cooked foods. These practices had the potential to affect all residents in the facility, as safe food handling and storage procedures were not consistently followed.
Failure to Provide Required Bed Hold Policy Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide a resident and their representative with written information regarding the bed hold policy, reserve bed payment policy, and the right to return to the facility when the resident was transferred to the hospital. Although the facility's policy requires that written information be given before any hospital transfer or therapeutic leave, including details on the duration of the bed hold, payment policies, and appeal rights, neither the resident nor their representative received such documentation at the time of transfer. The only documentation found was a Financial Consent to Bed Hold form signed at admission over three years prior, which did not meet the requirement for notification at the time of transfer. Staff interviews revealed that while the bed hold policy is reviewed and signed upon admission, the actual bed hold letter provided at the time of transfer lacked essential information such as the daily rate for bed reserve payment and did not include a signature line for acknowledgment. Staff also indicated that the bed hold notice is sent with the resident in a packet to the hospital, but is not directly discussed with the resident or their representative, and key details such as the daily rate and appeal rights are not communicated. The resident in question had moderate cognitive impairment and an activated Power of Attorney for Healthcare, further emphasizing the need for proper notification to the representative.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
Staff failed to consistently follow physician orders for oxygen administration for a resident with a history of hemiplegia, hemiparesis, spinal stenosis, major depressive disorder, and intervertebral disc disorder. The resident's care plan required the use of a BiPAP machine with 4 liters of oxygen at bedtime and during daytime naps, and the Treatment Administration Record (TAR) included orders for oxygen at 4 liters when using BiPAP. However, observations revealed that the oxygen concentrator was set below the ordered amount or was not turned on while the resident was using the BiPAP machine. On one occasion, the resident was observed asleep with the BiPAP machine in use and the oxygen concentrator set at only 1 liter. On another occasion, the concentrator was not turned on at all while the BiPAP was in use, and when it was turned on by an LPN, it was set at 1.5 liters, still below the ordered 4 liters. The DON confirmed that the oxygen concentrator should have been set at the level ordered by the physician.
Failure to Use Wheelchair Foot Pedal Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper use of a wheelchair foot pedal during the transport of a resident, leading to an accident. The resident, who had a medical history of hemiplegia and hemiparesis following a cerebral infarction affecting the right side, was dependent on staff for mobility and used a wheelchair. On the day of the incident, a CNA wheeled the resident to the dining room without the right foot pedal attached to the wheelchair. As a result, the resident's right foot was placed under the wheelchair, causing the resident to cry out in pain. The incident was witnessed by other staff members, including an LPN and an RN, who noted the absence of the foot pedal. The resident experienced increased pain on the right side, particularly in the leg, and an x-ray later revealed fractures in the ankle area. Despite the resident's history of right leg pain and swelling, the facility's investigation could not determine if the fractures were directly caused by the incident, as the resident's pain began prior to the staff's failure to use the foot pedal. Interviews with staff and the resident's responsible party confirmed the absence of the foot pedal during the incident and highlighted the resident's reliance on the left foot for wheelchair propulsion due to the stroke-affected right side.
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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.
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Nursing homes near Oconomowoc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Country Health Services | 4.7 mi | ★★★★★ | 10 | 0 |
| Masonic Center For Health & Rehab Inc. | 7.3 mi | ★★★★★ | 1 | 0 |
| Watertown Health Care Center | 10.6 mi | ★★★★★ | 25 | 0 |
| Marquardt Memorial Manor | 11 mi | ★★★★★ | 21 | 0 |
| Lindengrove Waukesha | 14.5 mi | ★★★★★ | 20 | 1 |
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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 July 2026) and official state health department websites.