Woodside Lutheran Home
1040 Pilgrim Way, Green Bay, WI 54304
Woodside Lutheran Home is a nursing home in Green Bay, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (920) 499-1481
- Last standard health inspection
- September 24, 2025 (1 year ago)
- Certified beds
- 118
- Residents per day, on average
- 87.4
- Ownership type
- Non profit - Church related
- Legal business name
- Bay Area Lutheran Homes INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (2 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
1 citation
Health inspection on September 24, 2025
CMS lists this as a standard inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 21, 2025.
12 citations
Fire safety inspection on September 24, 2025
CMS lists this as a standard inspection.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on December 11, 2025.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on December 4, 2025.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on September 26, 2025.
CMS has cited this home for K0711 2 times since 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 29, 2025.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on December 11, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 12, 2025.
CMS has cited this home for K0918 2 times since 2023.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on September 25, 2025.
Citation K0291. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on September 25, 2025.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on September 25, 2025.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on October 17, 2025.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on September 25, 2025.
CMS has cited this home for K0511 2 times since 2024.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on September 26, 2025.
CMS has cited this home for K0521 2 times since 2024.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 5 of 5.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
1 citation
Health inspection on July 31, 2024
CMS lists this as a standard inspection.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 16, 2024.
6 citations
Fire safety inspection on July 31, 2024
CMS lists this as a standard inspection.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on August 19, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 6, 2024.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 13, 2024.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on August 2, 2024.
Citation K0751. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of flammable curtains.
CMS lists it as corrected on August 1, 2024.
Citation K0753. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on August 19, 2024.
CMS update of February 29, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Ownership
CMS ownership records list new owners for this home.
1 citation
Fire safety inspection on June 28, 2023
CMS lists this as a standard inspection.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 8, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BAY AREA LUTHERAN HOMES INC5% or greater direct ownership interest · 100% · since 11/14/2006
- CLIFTONLARSONALLENOperational/managerial control · not applicable · since 01/01/2024
- GREENFIELD REHABILITATION AGENCY, INCOperational/managerial control · not applicable · since 06/01/2019
- HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INCOperational/managerial control · not applicable · since 06/29/2017
- PINNACLE INNOVATIVE HEALTHCARE SOLUTIONS, LLCOperational/managerial control · not applicable · since 01/01/2007
- WIPFLI LLPOperational/managerial control · not applicable · since 10/20/2013
- ANDERSON, PAMELAOperational/managerial control · not applicable · since 10/01/2022
- ATKINSON, JESSICAOperational/managerial control · not applicable · since 07/01/2023
- BAKE, ANDREWOperational/managerial control · not applicable · since 01/01/2022
- BREWER, KATHERINEOperational/managerial control · not applicable · since 06/01/2019
- CABINO, SARAHOperational/managerial control · not applicable · since 05/23/2016
- FRAZIER, LARRYOperational/managerial control · not applicable · since 01/01/2026
- GERVAIS, LISAOperational/managerial control · not applicable · since 08/28/2023
- GRETZINGER, POLLYOperational/managerial control · not applicable · since 07/01/2023
- LIM, ANNAOperational/managerial control · not applicable · since 10/01/2023
- MATZKE, DEANOperational/managerial control · not applicable · since 01/01/2026
- MAY, SUSANOperational/managerial control · not applicable · since 01/01/2023
- NELSON, LAURAOperational/managerial control · not applicable · since 01/01/2022
- PLETCHER, KATHYOperational/managerial control · not applicable · since 01/01/2022
- POOLE, MICHELLEOperational/managerial control · not applicable · since 06/01/2019
- RAAB, JERIOperational/managerial control · not applicable · since 01/01/2023
- ROTH, MAXIMILIANOperational/managerial control · not applicable · since 01/01/2024
- SCHROEDER, NORMANOperational/managerial control · not applicable · since 01/01/2022
- SEYMOUR, PAULOperational/managerial control · not applicable · since 01/01/2022
- VELDT, AMYOperational/managerial control · not applicable · since 01/01/2007
- VORPAGEL, EARLOperational/managerial control · not applicable · since 01/01/2024
Questions
When was Woodside Lutheran Home last inspected?
CMS lists September 24, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Woodside Lutheran Home have?
CMS lists 2 health citations since July 31, 2024. CMS also calls these deficiencies.
Has Woodside Lutheran Home been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Woodside Lutheran Home?
Its CMS overall star rating is 5 of 5.
Is Woodside Lutheran Home a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.