Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Woodside Lutheran Home
Green Bay, WI · 118 certified beds · Last Life Safety survey September 24, 2025
CMS Certification Number 525557 · first certified January 1995
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
19 citations — more than 54% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 12 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 1 month from now. This facility’s last Life Safety survey was September 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 19 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 28, 2023 | 1 |
| July 31, 2024 | 6 |
| September 24, 2025 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-09-24 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-09-24 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-09-24 |
| K-0711 | Provide a written emergency evacuation plan. | 2 | 2025-09-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-07-31 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2025-09-24 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1 | 2025-09-24 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 1 | 2024-07-31 |
What the citations cover
- Miscellaneous Deficiencies 6
- Smoke Deficiencies 4
- Services Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Miscellaneous Deficiencies | 6 |
| Smoke Deficiencies | 4 |
| Services Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 24, 2025 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (December 11, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 17, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (December 4, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (September 26, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (September 26, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 29, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 11, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 12, 2025) |
July 31, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 6, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 2, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0751 | Have restrictions on the use of flammable curtains. | Deficient, Provider has date of correction (August 1, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (August 19, 2024) |
June 28, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 8, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.