Cycle 1
Health 2025-09-24 · Fire 2025-09-24
1 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Green Bay, WI
Woodside Lutheran Home
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1040 Pilgrim Way, Green Bay, WI
(920) 499-1481
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
86
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.38
Registered nurse staffing
LPN hours / resident day
0.57
Licensed practical nurse staffing
Aide hours / resident day
3.43
Nurse aide staffing
Weekend hours
4.42
Weekend nurse staffing
RN turnover
32%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
95.7%
0.4 pts worse
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.0%
2.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.2%
1.9 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
5.0%
4.2 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
16.6%
1.1 pts worse
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.6% |
16.7%
8.9 pts worse
|
16.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.7% |
21.1%
9.6 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
17.3%
4.5 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
2.3%
0.1 pts better
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
3.0%
1.8 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
25.5%
4.6 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.5%
0.9 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
86.8%
9.2 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
15.0%
3.7 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.7% |
82.2%
10.5 pts better
|
79.7%
13 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
22.7%
2.7 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-31 · Fire 2024-07-31
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2023-06-28 · Fire 2023-06-28
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-12-11
F · Potential for more than minimal harm
2025-09-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-12-04
F · Potential for more than minimal harm
2025-09-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-26
F · Potential for more than minimal harm
2025-09-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-29
F · Potential for more than minimal harm
2025-09-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-12-11
F · Potential for more than minimal harm
2025-09-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-09-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-24
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 2025-09-25
E · Potential for more than minimal harm
2025-09-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-09-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-26
F · Potential for more than minimal harm
2024-07-31
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-02
E · Potential for more than minimal harm
2024-07-31
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-31
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-08-19
F · Potential for more than minimal harm
2023-06-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-21
E · Potential for more than minimal harm
2024-07-31
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-16
Penalties and ownership
What sits behind the stars
Ownership
Bay Area Lutheran Homes Inc
5% Or Greater Direct Ownership Interest · Organization
Anderson, Pamela
Corporate Director · Individual
Atkinson, Jessica
Corporate Director · Individual
Atkinson, Jessica
W-2 Managing Employee · Individual
Bake, Andrew
Corporate Director · Individual
Cabino, Sarah
W-2 Managing Employee · Individual
Gervais, Lisa
W-2 Managing Employee · Individual
Gretzinger, Polly
Corporate Director · Individual
Gretzinger, Polly
W-2 Managing Employee · Individual
Hardtke, Amy
Corporate Director · Individual
Kneizel, Judith
Corporate Director · Individual
Knudsen, Judith
Corporate Director · Individual
Lim, Anna
Contracted Managing Employee · Individual
May, Susan
Corporate Director · Individual
Nelson, Laura
Corporate Director · Individual
Pletcher, Kathy
Corporate Director · Individual
Raab, Jeri
Corporate Director · Individual
Schroeder, Norman
Corporate Director · Individual
Seymour, Paul
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
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
#2
Odd Fellow Home
Green Bay, WI
2-star overall rating with 2-star inspections with $97,228 in total fines with 11 recent health deficiencies with 8 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
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