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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.38
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.43
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.39
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.42
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.51
CMS adjusted RN staffing hours
Adjusted total hours
5.89
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
937
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.96
Composite VBP score used to determine payment impact.
Payment multiplier
1.0169
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.15
Baseline 20.62% · Performance 19.51% · Measure score 4.15 · Achievement 4.15 · Improvement 2.60
Healthcare-associated infections
5.74
Baseline 5.82% · Performance 6.12% · Measure score 5.74 · Achievement 5.74 · Improvement 0
Total nurse turnover
7.70
Baseline 39.62% · Performance 32.19% · Measure score 7.70 · Achievement 7.70 · Improvement 4.53
Adjusted total nurse staffing
7.19
Baseline 4.70 hours · Performance 5.12 hours · Measure score 7.19 · Achievement 7.19 · Improvement 3.44
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.09% |
10.72%
2.6 pts better
|
No Different than the National Rate · Eligible stays 258 · Observed rate 4.65% · Lower 95% interval 5.5% |
| Discharge to community | 68.08% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 245 · Observed rate 68.98% · Lower 95% interval 62.21% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.35% |
95.27%
4.1 pts better
|
Numerator 152 · Denominator 153 |
| Falls with major injury | 1.31% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 153 |
| Discharge self-care score | 47.2% |
53.69%
6.5 pts worse
|
Numerator 59 · Denominator 125 |
| Discharge mobility score | 61.6% |
50.94%
10.7 pts better
|
Numerator 77 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 2.61% |
2.29%
0.3 pts worse
|
Numerator 4 · Denominator 153 · Adjusted rate 2.81% |
| Healthcare-associated infections requiring hospitalization | 6.12% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 4.08% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 2.27% |
8.2%
5.9 pts worse
|
Numerator 5 · Denominator 220 |
| Staff flu vaccination coverage | 44.53% |
42%
2.5 pts better
|
Numerator 167 · Denominator 375 |
| Discharge function score | 62.4% |
56.45%
5.9 pts better
|
Numerator 78 · Denominator 125 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 87 · Denominator 87 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 32.31% |
25.2%
7.1 pts better
|
Numerator 21 · Denominator 65 |
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 · Q1 95.9% · Q2 94.2% · Q3 95.6% · Q4 95.5% · 4Q avg 95.3% |
| 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 · 4Q avg 97.4% |
| 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 · Q1 5.4% · Q2 4.3% · Q3 2.9% · Q4 7.6% · 4Q avg 5.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.6% · 4Q avg 0.8% |
| 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 1.5% · Q2 8.5% · Q3 6.6% · Q4 0.0% · 4Q avg 4.1% |
| 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 · Q1 19.1% · Q2 14.8% · Q3 17.7% · Q4 19.0% · 4Q avg 17.7% |
| 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 · Q1 27.1% · Q2 24.5% · Q3 26.4% · Q4 24.0% · 4Q avg 25.6% · 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 | 30.7% |
21.1%
9.6 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · 4Q avg 30.7% · Used in QM five-star |
| 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 · Q1 20.0% · Q2 28.8% · Q3 25.0% · Q4 12.7% · 4Q avg 21.8% · Used in QM five-star |
| 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 · Q1 4.1% · Q2 1.5% · Q3 1.4% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 4.1% · Q2 6.0% · Q3 3.0% · Q4 6.2% · 4Q avg 4.8% · Used in QM five-star |
| 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 · Q1 32.6% · Q2 30.0% · Q3 25.9% · Q4 31.9% · 4Q avg 30.1% |
| 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 · Q1 6.6% · Q2 7.1% · Q3 4.1% · Q4 8.0% · 4Q avg 6.4% · Used in QM five-star |
| 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 · Q1 96.6% · Q2 94.5% · Q3 96.2% · Q4 96.8% · 4Q avg 96.0% |
| 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 · Adjusted 18.7% · Observed 17.0% · Expected 10.1% · Used in QM five-star |
| 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 · Q1 0.6% · Q2 0.6% · Q3 1.2% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star |
| 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 · 4Q avg 92.7% |
| 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 · Adjusted 25.4% · Observed 21.0% · Expected 19.7% · Used in QM five-star |
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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