SAINT JOHNS ON THE LAKE
Open-data reference.
SAINT JOHNS ON THE LAKE is a non profit - church related facility in MILWAUKEE, WI with 27 certified beds and a 4-star overall CMS rating. The facility has 13 deficiency records on file.
1858 N PROSPECT AVE, MILWAUKEE, WI 53202
Phone: 4142722022
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525539
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 27
- Residents
- 22
- In Hospital
- No
- County
- Milwaukee
- Last Inspection
- Jun 3, 2025
Staffing Data
- RN Hours
- 1.31 (nat'l avg: 0.68)
- LPN Hours
- 0.84
- CNA Hours
- 2.95
- Total Nursing Hours
- 5.09 (nat'l avg: 3.89)
- PT Hours
- 0.07
- Nursing Turnover
- 44.4%
- RN Turnover
- 33.3%
What the CMS Record Reveals About SAINT JOHNS ON THE LAKE
SAINT JOHNS ON THE LAKE operates 27 certified beds in MILWAUKEE, WI with approximately 22 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (5★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 13 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 5.09 total nursing hours per resident day (national average 3.89), with RN coverage at 1.31 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, SAINT JOHNS ON THE LAKE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 44.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (13 most recent)
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Aug 29, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Jul 3, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 29, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 7, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 7, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 24, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 17, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 27, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 27, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Mar 27, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Mar 27, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 27, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 10.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 4.1% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 4.2% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 6.8% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 93.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 30.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 20.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 100.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 27.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 2.3% | Yes |
Penalty History
| Date | Type | Amount |
|---|---|---|
| Feb 21, 2023 | Fine | $33K |
| Feb 21, 2023 | Payment Denial | - |
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Frequently Asked Questions
What is the overall CMS rating for SAINT JOHNS ON THE LAKE?
What are the staffing levels at SAINT JOHNS ON THE LAKE?
How many beds does SAINT JOHNS ON THE LAKE have?
Does SAINT JOHNS ON THE LAKE have any deficiencies on record?
Has SAINT JOHNS ON THE LAKE received any fines or penalties?
Who owns SAINT JOHNS ON THE LAKE?
When was SAINT JOHNS ON THE LAKE last inspected?
What quality measures are tracked for SAINT JOHNS ON THE LAKE?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.