SNF
SAINT JOHNS ON THE LAKE
CCN: 525539 · MILWAUKEE, WI 53202 · Milwaukee County
CCRC
Overview
- Address
- 1858 N PROSPECT AVE, MILWAUKEE, WI 53202
- Phone
- 4142722022
- Certified beds
- 27
- Avg daily residents
- 22 (81% of beds filled)
- Ownership
- Non-profit (church-affiliated)
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1994-07-01
- Setting
- Urban
4 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 5.09 | 3.55 | 5.54 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 1.31 | 0.62 | 1.42 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.84 | 0.79 | 0.91 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.95 | 2.14 | 3.21 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 2.14 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.07 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
4.70
hrs / resident / day
RN (weekend)
0.94
hrs / resident / day
Total nurse (adjusted, weekend)
5.11
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
44.4%
annual
RN turnover
33.3%
annual
Administrators departed
1
last 12 months
Resident acuity
Nursing Case-Mix Index
1.26
higher acuity than avg
Case-Mix Index Ratio
0.91
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-06-03 | 6 | 6 | 0 | 60 | 1 | 60 |
| Cycle 2/3 (prior) | 2024-04-24 | 1 | 1 | 0 | 16 | 1 | 16 |
Total weighted health score
49.0
lower is better
Infection-control citations
0
last cycle
Deficiencies (13)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
12 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D | 2025-06-03 | 2025-07-07 |
| 0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | 2025-06-03 | 2025-07-07 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | 2025-06-03 | 2025-08-29 |
| 0880 | Provide and implement an infection prevention and control program. | F | 2025-06-03 | 2025-08-29 |
| 0881 | Implement a program that monitors antibiotic use. | D | 2025-06-03 | 2025-07-03 |
| 0908 | Keep all essential equipment working safely. | F | 2025-06-03 | 2025-08-29 |
| 0880 | Provide and implement an infection prevention and control program. | F | 2024-04-24 | 2024-05-24 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2023-02-21 | 2023-03-27 |
| 0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | 2023-02-21 | 2023-04-17 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2023-02-21 | 2023-03-27 |
| 0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | 2023-02-21 | 2023-03-27 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2023-02-21 | 2023-03-27 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2023-02-21 | 2023-03-27 |
Financial Health (FY 2023)
Operating performance
Operating Margin
-14.3%
Total Margin
-19.2%
Occupancy Rate
72.7%
Cost per Resident Day
$91
Revenue & costs
Net Patient Revenue
$4.5M
Total Costs
$722K
Net Income
-$833K
Balance sheet
Total Assets
$11.3M
Total Liabilities
$11.3M
Fund Balance
-$14K
Current Ratio
1.08
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Owner / manager organizations (3)
| Organization | Role | Association |
|---|---|---|
| SAINT JOHN'S COMMUNITIES, INC. | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/1994 |
| THE MEDICAL COLLEGE OF WISCONSIN INC | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2024 |
| US BANK NATIONAL ASSOCIATION | 5% OR GREATER MORTGAGE INTEREST | since 12/09/2015 |
Owner / manager individuals (5)
| Name | Role | Association |
|---|---|---|
| LOYD, MATTHEW | OPERATIONAL/MANAGERIAL CONTROL | since 01/16/2021 |
| PETITT, DOROTHY | OPERATIONAL/MANAGERIAL CONTROL | since 10/18/2021 |
| SALTNESS, RACHEL | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2024 |
| ANDERSON, RENEE | CORPORATE OFFICER | since 07/01/2011 |
| LEMMINGER, DAN | CORPORATE OFFICER | since 10/03/2011 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- Yes
- Hospital-based
- No
- Resident / family council
- Both
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 112 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $91 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 1.08 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicare Day Share (%) | 10.3% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-833,116 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $4,527,192 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 72.7% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -14.3% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $11,293,204 | metrics.total_assets |
| Cost Report | Total Costs ($) | $722,074 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $-14,413 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $11,307,617 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -19.2% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.91293 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 3.20775 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 1.41954 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 5.54022 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 5.11293 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 21.9 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.78789 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.14130 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.62103 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.55022 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.12914 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | — | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | — | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | — | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | — | Chain Average Staffing Rating |
| Provider Information | Chain ID | — | Chain ID |
| Provider Information | Chain Name | — | Chain Name |
| Provider Information | City/Town | MILWAUKEE | City/Town |
| Provider Information | CMS Certification Number (CCN) | 525539 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | Y | Continuing Care Retirement Community |
| Provider Information | County/Parish | Milwaukee | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1994-07-01 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 3 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 43.0541 | Latitude |
| Provider Information | Legal Business Name | SAINT JOHN'S COMMUNITIES, INC. | Legal Business Name |
| Provider Information | Location | 1858 N PROSPECT AVE,MILWAUKEE,WI,53202 | Location |
| Provider Information | Long-Stay QM Rating | 2 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -87.89 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 1 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 27 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | 0 | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | — | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.25768 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.91292 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 4 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Non profit - Church related | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 1858 N PROSPECT AVE | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | SAINT JOHNS ON THE LAKE | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 390 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 2 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 60 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 0 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 6 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-06-03 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 60 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 6 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 1 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-04-24 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 16 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 0 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 16 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 1 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.93744 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 33.3 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 2.14476 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.83946 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.94961 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.06755 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 1.30530 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 5.09437 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 3 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 5 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | WI | State |
| Provider Information | Telephone Number | 4142722022 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 4.70146 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 44.4 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 49.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Both | With a Resident and Family Council |
| Provider Information | ZIP Code | 53202 | ZIP Code |