Cycle 1
Health 2025-06-03 · Fire 2025-06-03
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Milwaukee, WI
Saint Johns On The Lake
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1858 N Prospect Ave, Milwaukee, WI
(414) 272-2022
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
27
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-07-01
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
1.31
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.95
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.09
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.14
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.70
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.42
CMS adjusted RN staffing hours
Adjusted total hours
5.54
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 48% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.56% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 3.51% · Lower 95% interval 5.74% |
| Discharge to community | 53.28% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 55.1% · Lower 95% interval 41.22% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 18 · Denominator 24 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 16 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 8% |
2.29%
5.7 pts worse
|
Numerator 2 · Denominator 25 · Adjusted rate 8.78% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 84.64% |
8.2%
76.4 pts better
|
Numerator 237 · Denominator 280 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 70.83% |
56.45%
14.4 pts better
|
Numerator 17 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.2%
3.6 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 10.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
4.9%
5.3 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
16.6%
3.4 pts worse
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
16.7%
14.4 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% · 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 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.8% |
21.1%
9.7 pts worse
|
16.3%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
17.3%
2.7 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.1% |
2.3%
1.8 pts worse
|
1.0%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
3.0%
1.2 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.8% |
25.5%
2.3 pts worse
|
19.8%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.8% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.5%
3.2 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
86.8%
7 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 88.2% · Q3 100.0% · Q4 96.4% · 4Q avg 93.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.4% |
15.0%
7.4 pts worse
|
12.0%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 18.8% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.2%
17.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
22.7%
8.6 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 21.9% · Expected 16.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-24 · Fire 2024-04-24
1 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-21 · Fire 2023-02-21
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-06-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-06-03
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 2025-07-02
E · Potential for more than minimal harm
2025-06-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-06-03
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-25
C · Minimal harm
2025-06-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-26
F · Potential for more than minimal harm
2024-04-24
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-04-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-14
C · Minimal harm
2024-04-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-24
F · Potential for more than minimal harm
2023-02-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-02-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-02-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-21
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-22
E · Potential for more than minimal harm
2023-02-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-03-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-03
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 2025-08-29
F · Potential for more than minimal harm
2025-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-06-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-06-03
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-03
F · Potential for more than minimal harm
2024-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-24
G · Actual harm
2023-02-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-21
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 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-27
Penalties and ownership
What sits behind the stars
Ownership
Anderson, Renee
Corporate Officer · Individual
Lemminger, Dan
Corporate Officer · Individual
Loyd, Matthew
Operational/Managerial Control · Individual
Petitt, Dorothy
Operational/Managerial Control · Individual
Saint John's Communities, Inc.
Operational/Managerial Control · Organization
Saltness, Rachel
Operational/Managerial Control · Individual
The Medical College Of Wisconsin Inc
Operational/Managerial Control · Organization
Us Bank National Association
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Edenbrook Lakeside
Milwaukee, WI
2-star overall rating with 2-star inspections with $138,434 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Jewish Home And Care Center
Milwaukee, WI
4-star overall rating with 3-star inspections with $8,959 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Milwaukee Catholic Home
Milwaukee, WI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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