Saint Johns on the Lake
1858 N Prospect Ave, Milwaukee, WI 53202
Saint Johns on the Lake is a nursing home in Milwaukee, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (414) 272-2022
- Last standard health inspection
- June 3, 2025 (1 year ago)
- Certified beds
- 27
- Residents per day, on average
- 21.5
- Ownership type
- Non profit - Church related
- Legal business name
- Saint John's Communities, INC.
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (14 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
1 citation
Health inspection on April 1, 2026
CMS lists this as a complaint inspection.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 30, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
6 citations
Health inspection on June 3, 2025
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on August 29, 2025.
CMS has cited this home for F0812 2 times since 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 29, 2025.
CMS has cited this home for F0880 3 times since 2023.
Citation F0908. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on August 29, 2025.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on July 7, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on July 7, 2025.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on July 3, 2025.
8 citations
Fire safety inspection on June 3, 2025
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on July 25, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 9, 2025.
CMS has cited this home for K0918 3 times since 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on July 2, 2025.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 2, 2025.
CMS has cited this home for K0324 2 times since 2023.
Citation K0541. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on June 25, 2025.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on July 9, 2025.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on June 25, 2025.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 26, 2025.
CMS has cited this home for K0712 2 times since 2024.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 5.5 to 4.9 hours per resident per day.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
1 citation
Health inspection on April 24, 2024
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 24, 2024.
5 citations
Fire safety inspection on April 24, 2024
CMS lists this as a standard inspection.
Citation K0132. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
CMS lists it as corrected on May 24, 2024.
CMS has cited this home for K0132 2 times since 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 24, 2024.
Citation K0341. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on May 24, 2024.
CMS has cited this home for K0341 2 times since 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 14, 2024.
CMS has cited this home for K0353 2 times since 2023.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on May 24, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Fine
CMS changed the fine from February 21, 2023 from $50,325 to $32,711.
6 citations
Health inspection on February 21, 2023
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 323 Wisconsin homes (13%) got a citation at the actual harm level in 2023.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 17, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 27, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 27, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 27, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on March 27, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 27, 2023.
8 citations
Fire safety inspection on February 21, 2023
CMS lists this as a standard inspection.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on March 22, 2023.
Citation K0341. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on March 22, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 22, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 22, 2023.
Citation K0132. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
CMS lists it as corrected on March 22, 2023.
Citation K0311. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on March 22, 2023.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on March 22, 2023.
Citation K0781. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on March 22, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- SAINT JOHN'S COMMUNITIES, INC.Direct ownership interest · not applicable · since 07/01/1994
- SAINT JOHN'S COMMUNITIES, INC.Operational/managerial control · not applicable · since 07/01/1994
- THE MEDICAL COLLEGE OF WISCONSIN INCOperational/managerial control · not applicable · since 10/01/2024
- LOYD, MATTHEWOperational/managerial control · not applicable · since 01/16/2021
- PETITT, DOROTHYOperational/managerial control · not applicable · since 10/18/2021
- SALTNESS, RACHELOperational/managerial control · not applicable · since 10/01/2024
Questions
When was Saint Johns on the Lake last inspected?
CMS lists June 3, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Saint Johns on the Lake have?
CMS lists 14 health citations since February 21, 2023. CMS also calls these deficiencies.
Has Saint Johns on the Lake been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Saint Johns on the Lake?
Its CMS overall star rating is 5 of 5.
Is Saint Johns on the Lake a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.