01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-24 | 1 | 2025-09-24 | 12 |
| Cycle 2 | 2024-07-31 | 1 | 2024-07-31 | 6 |
| Cycle 3 | 2023-06-28 | 0 | 2023-06-28 | 1 |
CMS CCN 5255572026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Woodside Lutheran Home
1040 Pilgrim Way · Green Bay, WI 54304 · Brown County
Certified beds118CMS provider file
Recent citation rows21current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
21 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-24 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2025-12-112025-09-24 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-212025-09-24 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-09-252025-09-24 · FIREK0291Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-09-252025-09-24 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-09-252025-09-24 · FIREK0341Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2025-10-172025-09-24 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2025-12-042025-09-24 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-09-252025-09-24 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-09-262025-09-24 · FIREK0711Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2025-09-262025-09-24 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-12-292025-09-24 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-12-112025-09-24 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-12-122024-07-31 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2024-08-162024-07-31 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-08-062024-07-31 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2024-08-132024-07-31 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-08-022024-07-31 · FIREK0711Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2024-08-192024-07-31 · FIREK0751Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of flammable curtains.
Correction field: Deficient, Provider has date of correction · 2024-08-012024-07-31 · FIREK0753Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2024-08-192023-06-28 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2023-07-0803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BAY AREA LUTHERAN HOMES INCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 11/14/2006
- BMO BANK NATIONAL ASSOCIATIONOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 08/12/2021
- NICOLET NATIONAL BANKOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 04/01/2024
- ANDERSON, PAMELAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- BAKE, ANDREWIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- FRAZIER, LARRYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2026
- MATZKE, DEANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2026
- MAY, SUSANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- NELSON, LAURAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- PLETCHER, KATHYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- RAAB, JERIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- ROTH, MAXIMILIANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SCHROEDER, NORMANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- SEYMOUR, PAULIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- VORPAGEL, EARLIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- ATKINSON, JESSICAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2023
- GRETZINGER, POLLYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2023
- CLIFTONLARSONALLEN LLPOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.23per resident day
RN hours1.41per resident day
Weekend nurse hours4.37per resident day
Staff turnover42.5%CMS reported field
06 / LOCAL RECORDS
Open the Green Bay ledger →Other published facilities nearby
Brown Cty Comm Treatment Ctr-Bayshore Village63 beds · CMS overall 5/537 citation rowsEdenbrook Of Green Bay90 beds · CMS overall 3/559 citation rowsGreen Bay Health Services125 beds · CMS overall 2/544 citation rowsOdd Fellow Home88 beds · CMS overall 2/567 citation rowsSerenity Spring Senior Living At Green Bay64 beds · CMS overall 5/522 citation rows