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 Saint Johns On The Lake during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities alleged that an RN "swatted" him, but the facility’s investigation was limited to interviews with the resident, the accused RN, and an LPN who entered the room after hearing the resident get loud and did not visually witness the alleged contact. Facility policy required a thorough investigation, including interviewing other potentially affected residents, which was not done. The investigation report referenced five days of wellness checks and a buddy system for the resident’s sense of safety, yet there was no documentation that wellness checks occurred, and the buddy system was not added to the resident’s care plan, which was not updated until more than two weeks after the incident.
Surveyors found that food items, including dinner rolls, sausage, and yogurt, were stored in open or torn packages and were not labeled or dated as required by facility policy. Staff confirmed that food should be dated after opening, but this was not consistently done, potentially affecting all residents who consume facility-prepared food.
The facility did not include the infection preventionist in its water management committee, failed to document corrective actions for out-of-range water control limits, and lacked protocols for addressing waterborne pathogen risks. Additionally, the facility did not monitor the dryer vent in the laundry room to ensure it remained clear of debris, and staff were unaware of its inspection status.
Surveyors found that the facility did not have a system in place to monitor or maintain the laundry dryer vents leading from the basement to the outside. The Maintenance Director was unaware of the vent's inspection status or location, and the vent was not included in routine checks by an external company. This issue had the potential to affect all residents in the facility.
A resident with dementia, depression, and insomnia was given a PRN order for Ativan without a required 14-day limitation or documented physician justification for continued use. The order remained active and the medication was administered multiple times, contrary to facility policy and regulatory requirements.
A resident with a diagnosis of depression was admitted without a completed PASARR Level 1 screen prior to admission, and although the Level 1 screen was later completed and indicated a major mental disorder, the required Level 2 PASARR screening was not performed as mandated by facility policy.
A resident who was receiving IV antibiotics for presumptive septic arthritis was not included on the facility's antibiotic stewardship line list, despite facility policy requiring all antibiotic regimens to be tracked. The omission was confirmed during a review of records and acknowledged by the Infection Preventionist.
The facility failed to maintain an adequate infection prevention and control program, particularly in its Water Management Plan and hand hygiene practices. The Water Management Plan lacked essential components, and staff did not follow hand hygiene policies, leading to potential infection risks.
Failure to Thoroughly Investigate Abuse Allegation and Update Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff abuse toward a resident and to promptly update the resident’s care plan with identified protective interventions. The resident had type 2 diabetes mellitus, diastolic heart failure, and dementia, with a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment, and was documented as able to make self understood and understand others, with no behaviors noted during the MDS assessment period. On the date of the incident, the resident alleged that an RN had “swatted” him after she tried to assist him from falling. The facility’s investigation report classified the allegation as not substantiated, citing lack of evidence, inconsistent recollection by the resident, and a witness statement. The facility’s written policy on misconduct requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be immediately and thoroughly investigated, including identifying and interviewing other staff or residents in the immediate area who may have witnessed what occurred, and examining and interviewing other residents potentially affected. In this case, the investigation consisted of three interviews: the accused RN, the resident, and an LPN who entered the room after hearing the resident getting loud. The LPN reported hearing the resident say “don’t swat at me” and later that the RN was far away from the resident and could not have swatted him, but the LPN did not visually witness the alleged swat and was not in the room at the time of the alleged contact. The DON and NHA both acknowledged that no like-resident interviews were conducted and indicated that no one else was interviewed because they believed no one else would have known anything. The investigation report stated that wellness checks would be implemented for five days and that a buddy system would be used to support the resident’s sense of protection and safety. However, when surveyors requested documentation, the DON and NHA were unable to locate any records of the five days of wellness checks, and later confirmed there was no documentation that these checks were completed. The resident’s care plan was not updated until more than two weeks after the incident, despite the allegation occurring earlier in the month. When the care plan was updated, it included a problem statement that the resident may report unsubstantiated allegations of staff mistreatment/abuse and may experience misperceptions, confusion, or emotional distress, with interventions to acknowledge and validate feelings and document allegations, but the buddy system intervention referenced in the investigation findings was not added to the care plan.
Failure to Properly Store and Label Food Items
Penalty
Summary
Surveyors observed that the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, partially used and undated food items were found in both the walk-in cooler and the resident floor main kitchen refrigerator. Open food packages, such as dinner rolls and sausage, were found in the kitchen walk-in freezer without labels or use-by dates, and some packages were torn open and only wrapped with saran wrap. Yogurt containers in the resident dining area refrigerator were also found without labels or dates. These observations were confirmed by interviews with the Director of Dining and Kitchen Director, who acknowledged that food items are supposed to be dated after opening, and that the lack of labeling was not in compliance with facility policy. The facility's own policy requires that all refrigerated and frozen foods be covered, labeled, and dated, and that foods be checked to ensure they are consumed by their safe use-by dates or discarded. Despite this, surveyors found multiple instances where these procedures were not followed, potentially affecting all 20 residents who consume food prepared by the facility. The deficiency was identified through direct observation, interviews with staff, and review of facility policy and procedures.
Deficient Infection Control Program and Water Management Oversight
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program in accordance with current standards of practice, specifically regarding its Water Management Plan (WMP) and laundry dryer ventilation. The WMP did not include the infection preventionist (IP) as a member of the water management committee, and there was no evidence of collaboration or communication between the IP and the maintenance department regarding water system infection risks. The WMP also lacked documentation of corrective actions to be taken when water control limits, such as temperature ranges, were not met. The facility's policy indicated that the Safety Committee, which oversees the WMP, consisted of administrative and maintenance personnel, but meeting participants were not listed, and the IP was not involved in discussions or decision-making related to waterborne pathogen prevention. Interviews with facility staff revealed that the maintenance department was primarily responsible for water system monitoring and that the IP was not included in WMP discussions or safety committee meetings. The maintenance director was uncertain about specific protocols for addressing out-of-range control limits and indicated that administration would be contacted if issues arose, but no formal procedures were in place for additional testing or water use restrictions. The IP confirmed a lack of involvement in water risk management and stated that, in the event of a positive legionella case or other waterborne pathogen concern, they would refer to CDC guidance but had no established process at the facility. Additionally, the facility did not monitor the dryer ventilation system in the basement laundry room to ensure that the vent leading outside remained clear and free of debris. The maintenance director acknowledged that the dryer vent was not included in routine inspections by an external company and was unsure of its condition or location. This lack of monitoring was confirmed during a tour of the laundry area, and facility leadership was made aware of the concern.
Failure to Monitor and Maintain Laundry Dryer Vents
Penalty
Summary
The facility failed to ensure a system was in place for monitoring and maintaining the laundry dryer vents that extend from the basement laundry room to the outside of the building. During a tour of the basement laundry room, the Maintenance Director stated that the vent leading from the facility dryers to the outside was not checked and was unsure of its exact location. The Maintenance Director also indicated that while an external company monitors some facility vents, the dryer vent was likely not included in their inspections. There was no knowledge of whether any buildup or debris was present in the vent, and the Director of Nursing was made aware of these concerns. This deficiency had the potential to affect all 21 residents residing in the facility. No specific residents were directly involved or affected at the time of the survey, and no additional medical history or resident conditions were noted in relation to this deficiency.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
A deficiency occurred when a resident with dementia, depression, and insomnia was prescribed a PRN (as needed) psychotropic medication, Ativan (Lorazepam), without a required 14-day limitation on the order. The facility's policy, consistent with federal regulations, mandates that PRN orders for psychotropic medications must be limited to 14 days unless the prescriber documents a clinical rationale for extending the order and specifies the duration. In this case, the resident's order for PRN Ativan was initiated with no end date and remained active beyond the 14-day period, with no documented justification from the attending physician or prescriber for the extended use. The resident's medical record showed frequent administration of Ativan for restlessness and anxiety, but lacked the necessary documentation to support continued use beyond the initial 14 days. The surveyor confirmed that the order was still active and that the resident continued to receive the medication. Interviews with the DON and RN supervisor revealed that the order was entered without a stop date by a new nurse, and there was no evidence of the required physician documentation to justify the ongoing PRN use.
Failure to Complete Required PASARR Level 2 Screening
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a required PASARR (Preadmission Screening and Resident Review) process was completed for a resident with a diagnosis of depression. The facility's policy requires that all admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process. In this case, the Level 1 PASARR screen, which should have been completed prior to admission, was instead completed on the day of admission. The Level 1 screen indicated the presence of a major mental disorder and the use of psychotropic medications, which should have triggered a Level 2 PASARR evaluation. Despite the Level 1 screen results indicating the need for further assessment, there was no documentation of a Level 2 PASARR being completed for the resident. The surveyor confirmed with the Director of Nursing that the Level 2 screen had not been completed and that the Level 1 screen had only recently been sent to the agency responsible for Level 2 reviews. This oversight resulted in the resident not receiving the required Level 2 PASARR evaluation within the appropriate timeframe as outlined by facility policy.
Failure to Include Resident on Antibiotic Stewardship Line List
Penalty
Summary
A deficiency occurred when the facility failed to include one of two residents reviewed for antibiotic stewardship on the facility's antibiotic line listing, as required by facility policy. The resident in question was admitted with diagnoses including atrial fibrillation and dementia, and had been prescribed intravenous (IV) Ceftriaxone for presumptive septic arthritis following a hospital stay. The resident's medication administration record confirmed that the antibiotic was administered over a period of several days. However, the resident was not added to the facility's antibiotic stewardship line list, which is used to monitor and track antibiotic use and infections as part of the infection prevention and control program. Interviews with the Infection Preventionist revealed that all residents receiving antibiotics, including those whose antibiotic regimens were initiated in the hospital, should be included on the line list per facility protocol. Upon review of the antibiotic stewardship binder, it was confirmed that the resident was not listed, and the Infection Preventionist acknowledged this omission, stating that the resident should have been included regardless of the presumptive nature of the antibiotic use. The Director of Nursing was also informed of this oversight.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program based on current standards of practice. Specifically, the facility's Water Management Plan (WMP) was found to be inadequate. It lacked knowledgeable team members, a detailed description and flow diagram of the water system, an assessment to identify locations where Legionella could grow and spread, control measures, acceptable control limits, corrective actions, and a process to confirm the WMP's implementation and effectiveness. During the survey, the Director of Maintenance and the Director of Nursing were unable to provide any documentation, policy, or procedure for the WMP, indicating a significant gap in infection control practices related to water management in the facility. Additionally, the facility staff did not adhere to the infection prevention and control policies related to hand hygiene. An observation of a Registered Nurse (RN) preparing and administering medications to a resident revealed multiple instances where the RN failed to wash or sanitize her hands after removing gloves and before donning new ones. The RN touched various surfaces, including a garbage can, and administered medications and eye drops without proper hand hygiene, which is a critical step in preventing the spread of infections. The facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing healthcare-associated infections, was not followed. The policy requires handwashing with soap and water or the use of an alcohol-based rub in specific situations, such as after contact with a resident or their environment, and after removing gloves. The observed RN did not comply with these guidelines, leading to potential risks of infection transmission among residents and staff. The Director of Nursing was informed of these observations but did not provide additional information or corrective actions at the time of the survey.
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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 Milwaukee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Lakeside | 0.3 mi | ★★★★★ | 3 | 0 |
| Jewish Home And Care Center | 0.5 mi | ★★★★★ | 22 | 3 |
| Milwaukee Catholic Home | 0.7 mi | ★★★★★ | 0 | 0 |
| Eastcastle Pl Bradford Ter Conv Ctr | 0.9 mi | ★★★★★ | 16 | 0 |
| Milwaukee Health And Rehab | 3.3 mi | ★★★★★ | 14 | 0 |
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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.