Cycle 1
Health 2024-11-06 · Fire 2024-11-06
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Oneida, WI
Anna John Resident Centered Care Community
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
2901 South Overland Road, Oneida, WI
(920) 869-2797
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
35
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.23
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.69
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
4.94
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
7.86
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.92
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
7.10
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.43
CMS adjusted RN staffing hours
Adjusted total hours
9.16
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.29% |
8.2%
1.1 pts better
|
Numerator 13 · Denominator 140 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 117 · Denominator 117 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.2
1.6 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.2%
1.4 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 3.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
5.0%
2.2 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 7.4% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
4.9%
0.8 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 3.8% · Q4 4.2% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.6% |
16.6%
10 pts better
|
19.6%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 7.4% · Q4 10.7% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
16.7%
9.5 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.1% |
21.1%
5 pts better
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
17.3%
1.8 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.0% · Q3 16.7% · Q4 12.5% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.3%
1.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 14.0% |
3.0%
11 pts worse
|
1.7%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.0% · Q3 14.8% · Q4 8.3% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.6% |
25.5%
17.9 pts better
|
19.8%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.6% · Q3 15.9% · Q4 4.3% · 4Q avg 7.6% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.5%
3.6 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.5% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
86.8%
7.2 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 94.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-04
F · Potential for more than minimal harm
2024-11-06
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-11-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-11-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-11-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-26
C · Minimal harm
2024-11-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-26
F · Potential for more than minimal harm
2023-09-20
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-09-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-09-20
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-09-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-09-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-09-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-20
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-10-13
F · Potential for more than minimal harm
2022-10-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-11-01
F · Potential for more than minimal harm
2022-10-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-10-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-01
D · Potential for more than minimal harm
2024-11-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-26
D · Potential for more than minimal harm
2023-09-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-10-16
D · Potential for more than minimal harm
2022-10-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-02
Penalties and ownership
What sits behind the stars
Ownership
Oneida Nation
5% Or Greater Direct Ownership Interest · Organization
Danforth, Debbie
W-2 Managing Employee · Individual
Larson, David
W-2 Managing Employee · Individual
Rosner, Jennie
W-2 Managing Employee · Individual
White, Danielle
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Woodside Lutheran Home
Green Bay, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Rennes Health and Rehab Center-De Pere
De Pere, WI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Green Bay Health Services
Green Bay, WI
2-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out