Saint Johns On The Lake

Inspection findings

1. Apr 1, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Apr 30, 2026 · CMS health inspection

2. Jun 3, 2025 Fire Safety · 14 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jul 25, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Jul 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jul 7, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Jul 3, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jul 2, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jul 2, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Jun 25, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 26, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jul 9, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jul 9, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jun 25, 2025 · CMS fire safety

3. Apr 24, 2024 Health · 6 findings
   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 24, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 14, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 24, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 24, 2024 · CMS fire safety

4. Feb 21, 2023 Health · 14 findings
   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 27, 2023 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Apr 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 27, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Mar 27, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 27, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 27, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Mar 22, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Mar 22, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected Mar 22, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 22, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Mar 22, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 22, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Mar 22, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 22, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ANDERSON, CASSANDRA — adp of the snf, NOT APPLICABLE, since 03/14/2022
• ANDERSON, RENEE — corporate officer, NOT APPLICABLE, since 07/01/2011
• ANDERSON, RENEE — adp of the snf, NOT APPLICABLE, since 07/01/2011
• ARMBRUSTER, KATHY — adp of the snf, NOT APPLICABLE, since 10/01/2016
• ARNDT, BETTY — adp of the snf, NOT APPLICABLE, since 05/01/2022
• BEAL, POLLY — adp of the snf, NOT APPLICABLE, since 05/02/2014
• BECKLEY MILNER, DIANE — adp of the snf, NOT APPLICABLE, since 05/01/2018
• BURKE, ERIN — adp of the snf, NOT APPLICABLE, since 11/04/2019
• BUTLER, HELENE — adp of the snf, NOT APPLICABLE, since 05/24/1999
• COBURN, MATTHEW — adp of the snf, NOT APPLICABLE, since 05/01/2021
• COPPERNOLL, LEE — adp of the snf, NOT APPLICABLE, since 05/01/2018
• EAGER, DAVID — adp of the snf, NOT APPLICABLE, since 05/01/2023
• EXUM-PRYOR, LAKESHIA — adp of the snf, NOT APPLICABLE, since 07/23/2018
• FRY, WILLIAM — adp of the snf, NOT APPLICABLE, since 05/01/2024
• GESZVAIN, MELISSA — adp of the snf, NOT APPLICABLE, since 09/03/2019
• GUNTER, MATTHEW — adp of the snf, NOT APPLICABLE, since 06/01/2024
• HENDERSON, ANTONIO — adp of the snf, NOT APPLICABLE, since 06/22/2020
• HILDEBRAND, KIRSTEN — adp of the snf, NOT APPLICABLE, since 05/01/2023
• KELNHOFER, ALAN — adp of the snf, NOT APPLICABLE, since 01/12/2025
• LEMMINGER, DAN — corporate officer, NOT APPLICABLE, since 10/03/2011
• LEMMINGER, DAN — adp of the snf, NOT APPLICABLE, since 10/03/2011
• LOYD, MATTHEW — adp of the snf, NOT APPLICABLE, since 01/18/2021
• LOYD, MATTHEW — operational/managerial control, NOT APPLICABLE, since 01/16/2021
• LUTHER, ANNE — adp of the snf, NOT APPLICABLE, since 08/29/2007
• MASS, OMAR — adp of the snf, NOT APPLICABLE, since 02/14/2022
• MOON, JUDITH — adp of the snf, NOT APPLICABLE, since 05/02/2015
• PATRINOS, DANIEL — adp of the snf, NOT APPLICABLE, since 05/01/2023
• PETITT, DOROTHY — operational/managerial control, NOT APPLICABLE, since 10/18/2021
• PETITT, DOROTHY — adp of the snf, NOT APPLICABLE, since 10/18/2021
• SALTNESS, RACHEL — operational/managerial control, NOT APPLICABLE, since 10/01/2024
• SALTNESS, RACHEL — adp of the snf, NOT APPLICABLE, since 10/01/2024
• SCHREINER, RICHARD — adp of the snf, NOT APPLICABLE, since 05/01/2024
• WHITESIDE, CAZMER — adp of the snf, NOT APPLICABLE, since 05/13/2024
• BEHAVIORAL SOLUTIONS INC — adp of the snf, NOT APPLICABLE, since 10/01/2024
• BRIGHTON HOSPICE WISCONSIN LLC — adp of the snf, NOT APPLICABLE, since 08/07/2023
• COMMUNITY FOOT AND ANKLE CLINIC INC — adp of the snf, NOT APPLICABLE, since 02/26/2019
• DAVIS CLINICAL CONSULTING — adp of the snf, NOT APPLICABLE, since 12/30/2024
• DIETITIANS ON DEMAND CORPORATE SOLUTIONS, LLC — adp of the snf, NOT APPLICABLE, since 01/31/2022
• GUARDIAN PHARMACY OF MADISON, LLC — adp of the snf, NOT APPLICABLE, since 08/01/2023
• HEARING CARE AT HOME LLC — adp of the snf, NOT APPLICABLE, since 12/08/2022
• HOMETOWN HOSPICE & HOMECARE INC — adp of the snf, NOT APPLICABLE, since 09/17/2014
• INTEGRATED THERAPY MANAGMENT PARTNERS, LLC — adp of the snf, NOT APPLICABLE, since 02/01/2024
• KARE TECHNOLOGIES LLC — adp of the snf, NOT APPLICABLE, since 01/01/2023
• LEGACY HOSPICE CARES LLC — adp of the snf, NOT APPLICABLE, since 04/13/2022
• MADISON MEDICAL AFFILIATES INC — adp of the snf, NOT APPLICABLE, since 12/05/2013
• PREFERRED DENTISTRY ASSOCIATES, LLC — adp of the snf, NOT APPLICABLE, since 07/01/2024
• SAINT JOHN'S COMMUNITIES, INC. — adp of the snf, NOT APPLICABLE, since 07/01/1994
• 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 INC — operational/managerial control, NOT APPLICABLE, since 10/01/2024
• THE MEDICAL COLLEGE OF WISCONSIN INC — adp of the snf, NOT APPLICABLE, since 06/23/2025
• US BANK NATIONAL ASSOCIATION — 5% or greater mortgage interest, NOT APPLICABLE, since 12/09/2015