Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anna John Resident Centered Care Community during CMS and state inspections, most recent first.
Kitchen sanitation was not maintained in accordance with FDA Food Code standards. Surveyors observed dust and dark debris on ceiling tiles, vents, and a ceiling grid above the steam table and clean dish storage area, along with grease-like buildup on cooking equipment. Staff confirmed the steam table area was used to hold and plate resident food and that the ceiling had only been cleaned every couple of months. Surveyors also found that staff checked sanitizer PPM in the 3-compartment sink and a bucket without verifying water temperature, even though the test strip instructions required the solution to be 65 to 75 degrees F.
Missed Quarterly MDS Assessments: The facility did not complete required Quarterly MDS assessments for 5 of 42 sampled residents. Record review showed multiple OBRA assessments were overdue, including residents with prior Comprehensive or Quarterly MDSs on file. The NHA stated MDS work was outsourced to a contracted agency and acknowledged inaccuracies and discrepancies in assessment completion, while the MDS RN said the agency initiates the assessments and the RN transmits them when told they are complete.
The facility did not timely transmit required RAI/MDS records for multiple residents, including late admission, quarterly, annual, comprehensive, discharge, death tracking, entry tracking, and reentry tracking assessments. Survey review found several assessments were completed and sent well after the required timeframe, while others were not transmitted at all. The NHA said MDS work had been outsourced to a contracted agency, and the MDS RN stated she transmitted assessments to iQIES when the agency said they were complete but was unsure why some were late or missing.
Inaccurate MDS coding affected multiple residents. A resident’s Tracking MDS listed the wrong admission date and entry type after a hospital return, another resident’s MDS incorrectly showed hospice services in the facility even though hospice had ended before admission, a resident with schizoaffective disorder and PTSD had MDSs that omitted those diagnoses, and another resident’s Tracking MDS listed reentry instead of admission. The NHA acknowledged the inaccuracies and stated the MDSs were being completed through a contracted agency.
A resident with sleep apnea had a CPAP machine at the bedside and reported using it nightly, but the chart did not contain an OSA diagnosis, physician order, care plan, or documentation for monitoring, cleaning, or maintenance of the device. The NHA and RN reviewed the record and could not find supporting documentation for the CPAP or related instructions.
The facility failed to maintain an infection prevention and control program during COVID-19 testing when an RN wore the same disposable isolation gown while swabbing two residents. The RN removed gloves and performed hand hygiene between residents but did not remove the gown, and the IP and Interim DON stated the facility had been reusing disposable gowns for testing despite having no current PPE shortage and no policy for disposable gown reuse.
A resident with multiple medical conditions fell and sustained injuries during a shower when a CNA did not follow the care plan requiring two-person assistance. The facility's investigation lacked documentation of resident interviews and not all nursing staff received required education on care plan adherence.
A resident with a venous stasis ulcer did not receive appropriate care as the facility failed to conduct weekly wound assessments and delayed notifying the physician of changes in the wound condition. Despite being seen by a wound clinic and vascular surgeon, the facility did not adhere to its policies for wound management and timely communication, potentially impacting the resident's treatment outcomes.
Kitchen Sanitation and Sanitizer Testing Deficiencies
Penalty
Summary
Food was not stored and prepared in a sanitary manner in the kitchen. During an initial tour, ceiling tiles and a metal grid above the steam table and in the area where clean dishes were stored were observed with dust particles. Under the ceiling vents in the steam table area, plastic covers used to cover plated food were present, and dark areas with dust adhered to the vents were also observed. The steam table area was identified by staff as the main area where cooked food was held and plated for residents. Additional observations showed a grease-like film with dust and debris on the sides of equipment used to cook and fry food. The Registered Dietitian stated the facility followed the FDA Food Code and later confirmed the ceiling tiles and vents contained dust. The Registered Dietitian and maintenance staff stated the ceiling had been cleaned only every couple of months, and the Registered Dietitian later provided a cleaning schedule that had been changed to monthly cleaning. After the ceiling tiles, vents, and equipment were cleaned during the survey, no dark-colored debris or dust particles remained where the cleaning had been done. The facility also did not verify the temperature of water mixed with sanitizing solution when testing sanitizer strength in the three-compartment sink and in a red bucket used to wipe kitchen and food prep surfaces. Staff stated the sanitizer was Quat and that Hydrian test strips were used to check PPM, but the temperature of the solution was not checked with a thermometer. The test strip instructions reviewed by the surveyor stated the solution should be between 65 and 75 degrees F when tested, and the PPM log near the sink did not include a space for temperature.
Missed Quarterly MDS Assessments
Penalty
Summary
The facility did not complete Quarterly MDS assessments within the required timeframe for 5 of 42 sampled residents. Review of the facility’s MDS submission showed that R23’s Quarterly MDS due in December 2025 was not completed, R25’s Quarterly MDS due in September 2025 was not completed, R32’s Quarterly MDS due in August 2025 was not completed, R42’s Quarterly MDSs due in March 2025 and September 2025 were not completed, and R43’s Quarterly MDSs due in February 2025 and May 2025 were not completed. The RAI Manual states that OBRA assessments are due every quarter unless the resident is no longer in the facility and that there must be no more than 92 days between OBRA assessments. Record review showed that R23 had a Comprehensive MDS completed on 9/10/25, R25 had a Comprehensive MDS completed on 6/25/25, R32 had a Comprehensive MDS completed on 5/9/25, R42 had a Comprehensive MDS completed on 11/29/24, and R43 had a Quarterly MDS completed on 11/27/24. During interview, the NHA stated the facility outsourced MDS assessments to a contracted agency in July 2025 and acknowledged inaccuracies in the MDS assessments and discrepancies with the contracted agency’s completion of assessments. The MDS RN stated the contracted agency initiates the assessments, has access to residents’ records, completes the nursing sections based on information provided by the RN, and the RN transmits the assessments when the contracted agency indicates they are complete.
Late and Missing MDS Transmissions
Penalty
Summary
The facility did not ensure timely transmittal of Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments for 18 of 49 sampled residents. Survey review found multiple required assessments and tracking records were either transmitted late or not transmitted at all, including discharge assessments, admission assessments, quarterly assessments, annual and comprehensive assessments, death tracking, entry tracking, and reentry tracking records. Examples included residents whose discharge assessments were not transmitted until many months after discharge, residents whose admission, quarterly, annual, or comprehensive assessments were completed and transmitted outside the required timeframe, and residents for whom required tracking records were missing entirely. The record review also showed that one resident who returned from hospitalization did not have a Reentry Tracking MDS completed, another hospitalized resident did not have a Discharge MDS transmitted, and one resident who died at the facility did not have a Death Tracking MDS transmitted. During interviews, the NHA stated the facility outsourced MDS completion to a contracted agency in July 2025 and acknowledged inaccuracies in the assessments and discrepancies identified with the contractor. The MDS RN stated the contracted agency initiated assessments and RN-J transmitted them to iQIES when the agency indicated they were complete, but was unsure why some assessments were not transmitted timely or not transmitted at all.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility did not accurately code MDS 3.0 assessments for 4 residents sampled by surveyors. For R14, the Tracking MDS dated 7/21/25 listed the admission date as 7/21/25 instead of 10/17/24 and identified the entry type as admission instead of reentry, even though R14 had been admitted to the facility, hospitalized, and then returned on 7/21/25. The NHA stated the facility outsourced MDS assessments to a contracted agency in July 2025 and acknowledged inaccuracies in the assessments. The MDS RN stated the contracted agency initiates the assessments, has access to resident records, and completes the nursing sections using information provided by the facility. For R2, the MDS dated 1/6/26 indicated hospice services were received in the facility, but R2 had signed off hospice prior to admission and did not receive hospice services in the facility; the NHA confirmed the assessment was inaccurate and stated the facility had an in-house comfort care program, but was not a licensed hospice provider. For R43, who had diagnoses of schizoaffective disorder and PTSD, the MDS assessments with ARDs of 7/11/25 and 10/20/25 did not include those diagnoses, and the NHA confirmed they should have been reflected. For R49, the Tracking MDS dated 4/16/25 identified the entry type as reentry instead of admission, despite R49 being admitted to the facility; the NHA again acknowledged inaccuracies in the MDS assessments.
Missing CPAP Orders and Documentation
Penalty
Summary
Appropriate respiratory care and services were not provided for one resident who had a CPAP machine on the nightstand and reported using it nightly for sleep apnea. The resident’s record showed intact cognition and self-decision-making ability, and a hospital discharge summary referenced OSA/obesity hypoventilation syndrome, but the facility record did not contain a diagnosis of OSA, a physician order for CPAP use, or a care plan for the machine. A physician note documented sleep apnea and that CPAP was pending, but no supporting order or treatment documentation was found in the chart. The resident told the surveyor that the CPAP machine had been obtained after a sleep test at the facility about a month earlier, that staff helped remove the mask in the morning, and that staff cleaned the mask and tubing two to three times per week. Surveyors observed the CPAP equipment connected and a partially used gallon of distilled water beside the nightstand. The nursing home administrator and RN reviewed the record and could not find documentation for the resident’s CPAP machine, OSA diagnosis, or instructions for care, cleaning, monitoring, or maintenance of the device.
Infection Control Lapse During COVID-19 Testing
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for two residents observed during COVID-19 testing. During observation, RN-E wore a disposable isolation gown, surgical mask, eye protection, and gloves while testing R47, then removed gloves and performed hand hygiene but did not remove the disposable gown before entering R12’s room to perform another COVID-19 antigen nasal swab. RN-E stated the same gown could be worn throughout testing unless a resident was on droplet precautions, in which case the gown and gloves would be disposed of after the test. The Infection Preventionist stated staff wore the same reusable isolation gown when testing residents for COVID-19 unless a resident was symptomatic or on transmission-based precautions, but also stated the facility did not have a policy for the reuse of disposable isolation gowns. The Interim DON stated staff had reused disposable gowns since the beginning of COVID-19 for testing unless a resident was on TBP and verified the practice was outdated. The facility was in a COVID-19 outbreak at the time of the observation and was not in a PPE shortage.
Failure to Thoroughly Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential neglect involving a resident who fell during a shower provided by a CNA. The resident, who had diagnoses including autism, long-term use of anticoagulants, central pain syndrome, gait and mobility abnormalities, contracture of the left hand, and general muscle weakness, required the assistance of two staff for transfers, pericare, and showers according to the care plan. During the incident, the CNA did not follow the care plan, resulting in the resident standing alone in the shower, falling, and sustaining a head and left shoulder abrasion. The facility's investigation was incomplete, lacking documentation of resident interviews that were reportedly conducted, and failing to include which residents were interviewed. Additionally, not all nursing staff received the required education on following care plans, as evidenced by missing signatures on education sign-in sheets and confirmation from the DON that some staff who had worked since the incident had not yet been educated. These actions and omissions did not meet the facility's policy requirements for a systematic and thorough investigation of alleged neglect.
Failure to Provide Timely Wound Care and Physician Notification
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, R10, who was admitted with a venous stasis ulcer on the right great toe. The facility did not complete weekly wound assessments or notify R10's physician in a timely manner when changes were noted in the wound. R10 had a history of peripheral vascular disease, type 2 diabetes mellitus, and other significant health issues, which contributed to the complexity of the wound care required. Despite being seen by a wound clinic and a vascular surgeon, the facility did not adhere to its own policies for wound management and notification of changes in condition. R10's medical record indicated that the facility failed to conduct weekly wound assessments and did not document measurements of the right great toe between early April and mid-May. Additionally, after R10's return from the hospital in late May, the facility did not complete weekly wound assessments with measurements for the left toe. The facility's staff documented daily observations of the wound but failed to notify the physician of significant changes in the wound condition until several days after they were first noted. This delay in communication potentially impacted the timely management of R10's condition. Interviews with facility staff, including the Director of Nursing and Assistant Director of Nursing, confirmed that the facility did not follow its policies for wound care and timely physician notification. The staff acknowledged that weekly wound notes should have been completed and that the physician should have been contacted when changes were observed. The wound clinic also indicated that earlier notification of changes might have led to different clinical decisions, such as sending R10 to the emergency department for more immediate assessment.
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What surveyors actually found near you
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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 Oneida
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodside Lutheran Home | 4.6 mi | ★★★★★ | 0 | 0 |
| Rennes Health And Rehab Center-de Pere | 5.3 mi | ★★★★★ | 9 | 0 |
| Ccc Of West Green Bay | 5.6 mi | — | 0 | 0 |
| Green Bay Health Services | 5.8 mi | ★★★★★ | 0 | 0 |
| Serenity Spring Senior Living At Green Bay | 6.1 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.