ST. JOHNS ON THE LAKE

The information listed below provides an in-depth look into the type and quality of care offered at St. Johns on the Lake. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

ST. JOHNS ON THE LAKE
1840 N PROSPECT AVE
MILWAUKEE, WI 53202
(414) 272-2022

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

86%

Number of Residents and Certified Beds

  • Residents: 48
  • Certified Beds: 56

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By Non Profit - Church Related
  • Offers Only Resident Counseling
  • Part of a Continuing Care Retirement Community (CCRC)
  • This Facility is Not Part of a Chain or Franchise

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Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by St. Johns on the Lake. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 6-108.1%
ADL Index Range: 0-557.5%
Total Percent:65.5%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 6-108.7%
ADL Index Range: 0-522.0%
Total Percent:30.7%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 0-53.7%
Total Percent:3.7%
 

Rating Details For St. Johns on the Lake

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours1 Hour and 4 Minutes57 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours46 Minutes35 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 29 Minutes1 Hour and 58 Minutes
Total Licensed Nurse Hours1 Hour and 50 Minutes1 Hour and 32 Minutes
Total Nurse Hours4 Hours and 19 Minutes3 Hours and 30 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Wisconsin are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityWisconsin Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%95%
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%94%

Long-Term Stay Deficiencies

Percent of High-Risk Long-Stay Residents Who Have Pressure Sores29%8%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse8%11%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair3%3%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder6%7%
Percent of Long-Stay Residents Who Are More Depressed or Anxious15%18%
Percent of Long-Stay Residents Who Lose Too Much Weight4%8%
Percent of Long-Stay Residents Who Were Physically Restrained-3%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain2%4%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased12%14%
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores4%3%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection8%8%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder39%49%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination85%92%
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season90-100%90%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Have Delirium-3%
Percent of Short-Stay Residents Who Have Pressure Sores12%10%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain52%26%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 03/31/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/29/2011
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/29/2011

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009

Pharmacy Service

Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/30/2011

Quality Care

Give Professional Services That Meet a Professional Standard of Quality.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 01/14/2010
  • Correction Date: 02/14/2010

Resident Assessment

Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009
Make Sure That Doctors Visit Residents Regularly, As Required.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 01/14/2010
  • Correction Date: 02/14/2010
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
  • Inspection Date: 01/14/2010
  • Correction Date: 02/14/2010

Resident Rights

Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
  • Inspection Date: 04/01/2009
  • Correction Date: 04/29/2009

Enforcement

Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.

Action TakenDateAmount
Civil Money Penalty (CMP)04/01/2009$4,355

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for St. Johns on the Lake, as well as complaints by residents or their family in the previous three years.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Formal ComplaintsDegree of HarmResidents Affected

Administration

Post Nurse Staffing Information.
  • Complaint Filed: 04/01/2009
  • Correction Date: 04/29/2009

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Complaint Filed: 07/06/2010
  • Correction Date: 07/23/2010

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that St. Johns on the Lake had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 04/06/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/27/2009
Properly Working Alarms on Sprinkler Valves.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/09/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/09/2009
Portable Fire Extinguishers.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/09/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 04/06/2011
  • Correction Date: 04/16/2011
Portable Fire Extinguishers.
  • Inspection Date: 04/06/2011
  • Correction Date: 04/16/2011

Building Construction

A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/10/2009
Approved Construction Type or Materials.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/08/2009
A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010
A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 04/06/2011
  • Correction Date: 04/19/2011

Building Service Equipment

Properly Constructed Linen or Trash Chutes.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/09/2009

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/08/2009

Electrical

Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/09/2009
Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 04/06/2011
  • Correction Date: 04/11/2011

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010

Exits and Egress

Exits That Are Accessible at All Times.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010
Corridors or Aisles That Are Unobstructed and Are at Least 8 Feet in Width.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010
Rooms That Can Be Unlocked from Inside Without a Key.
  • Inspection Date: 04/06/2011
  • Correction Date: 05/18/2011

Fire Alarm Systems

An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 03/30/2009
  • Correction Date: 05/30/2009
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010

Illumination and Emergency Power

Emergency Lighting That Can Last at Least 1 1/2 Hours.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/01/2009
Proper Medical Gas Storage and Administration Areas.
  • Inspection Date: 04/06/2011
  • Correction Date: 05/31/2011

Miscellaneous

Fire Safety Features Required by Current Fire Safety Codes.
  • Inspection Date: 03/30/2009
  • Correction Date: 04/07/2009
Fire Safety Features Required by Current Fire Safety Codes.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010

Smoke Compartmentation and Control

Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
  • Inspection Date: 03/30/2009
  • Correction Date: 05/30/2009
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
  • Inspection Date: 04/19/2010
  • Correction Date: 05/19/2010
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
  • Inspection Date: 04/06/2011
  • Correction Date: 05/31/2011
Source: Medicare Nursing Home Compare; Dept of Health and Family Services of WI-Division of Supportive Living-Bureau of Quality Assurance - Retrieved 2011