Woodside Lutheran Home

Inspection findings

1. Sep 24, 2025 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Dec 11, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 21, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Sep 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Sep 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Oct 17, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Dec 4, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Sep 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Sep 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Sep 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Dec 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Dec 11, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Dec 12, 2025 · CMS fire safety

2. Jul 31, 2024 Health · 7 findings
   • Not serious Scope/severity E

     F0761 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.

     Corrected Aug 16, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 13, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 2, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Aug 19, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0751 Miscellaneous Deficiencies

     Have restrictions on the use of flammable curtains.

     Corrected Aug 1, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Aug 19, 2024 · CMS fire safety

3. Jun 28, 2023 Fire Safety · 1 finding
   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jul 8, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ANDERSON, PAMELA — corporate director, NOT APPLICABLE, since 01/01/2022
• ANDERSON, PAMELA — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• ANDERSON, PAMELA — adp of the snf, NOT APPLICABLE, since 01/01/2022
• ATKINSON, JESSICA — corporate officer, NOT APPLICABLE, since 07/01/2023
• ATKINSON, JESSICA — operational/managerial control, NOT APPLICABLE, since 07/01/2023
• ATKINSON, JESSICA — adp of the snf, NOT APPLICABLE, since 07/01/2023
• BAKE, ANDREW — corporate director, NOT APPLICABLE, since 01/01/2022
• BAKE, ANDREW — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• BAKE, ANDREW — adp of the snf, NOT APPLICABLE, since 01/01/2022
• BREWER, KATHERINE — adp of the snf, NOT APPLICABLE, since 06/01/2019
• BREWER, KATHERINE — operational/managerial control, NOT APPLICABLE, since 06/01/2019
• CABINO, SARAH — operational/managerial control, NOT APPLICABLE, since 05/23/2016
• CABINO, SARAH — adp of the snf, NOT APPLICABLE, since 05/23/2016
• FRAZIER, LARRY — corporate director, NOT APPLICABLE, since 01/01/2026
• FRAZIER, LARRY — adp of the snf, NOT APPLICABLE, since 01/01/2026
• FRAZIER, LARRY — operational/managerial control, NOT APPLICABLE, since 01/01/2026
• GERVAIS, LISA — operational/managerial control, NOT APPLICABLE, since 08/28/2023
• GERVAIS, LISA — adp of the snf, NOT APPLICABLE, since 08/28/2023
• GRETZINGER, POLLY — corporate officer, NOT APPLICABLE, since 07/01/2023
• GRETZINGER, POLLY — adp of the snf, NOT APPLICABLE, since 07/01/2023
• GRETZINGER, POLLY — operational/managerial control, NOT APPLICABLE, since 07/01/2023
• LIM, ANNA — operational/managerial control, NOT APPLICABLE, since 10/01/2023
• LIM, ANNA — adp of the snf, NOT APPLICABLE, since 10/01/2023
• MATZKE, DEAN — adp of the snf, NOT APPLICABLE, since 01/01/2026
• MATZKE, DEAN — operational/managerial control, NOT APPLICABLE, since 01/01/2026
• MATZKE, DEAN — corporate director, NOT APPLICABLE, since 01/01/2026
• MAY, SUSAN — adp of the snf, NOT APPLICABLE, since 01/01/2023
• MAY, SUSAN — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• MAY, SUSAN — corporate director, NOT APPLICABLE, since 01/01/2023
• NELSON, LAURA — adp of the snf, NOT APPLICABLE, since 01/01/2022
• NELSON, LAURA — corporate director, NOT APPLICABLE, since 01/01/2022
• NELSON, LAURA — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• PLETCHER, KATHY — adp of the snf, NOT APPLICABLE, since 01/01/2022
• PLETCHER, KATHY — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• PLETCHER, KATHY — corporate director, NOT APPLICABLE, since 01/01/2022
• POOLE, MICHELLE — adp of the snf, NOT APPLICABLE, since 06/01/2019
• POOLE, MICHELLE — operational/managerial control, NOT APPLICABLE, since 06/01/2019
• RAAB, JERI — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• RAAB, JERI — corporate director, NOT APPLICABLE, since 01/01/2023
• RAAB, JERI — adp of the snf, NOT APPLICABLE, since 01/01/2023
• ROTH, MAXIMILIAN — adp of the snf, NOT APPLICABLE, since 01/01/2024
• ROTH, MAXIMILIAN — corporate director, NOT APPLICABLE, since 01/01/2024
• ROTH, MAXIMILIAN — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• SCHROEDER, NORMAN — corporate director, NOT APPLICABLE, since 01/01/2022
• SCHROEDER, NORMAN — adp of the snf, NOT APPLICABLE, since 01/01/2022
• SCHROEDER, NORMAN — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• SEYMOUR, PAUL — operational/managerial control, NOT APPLICABLE, since 01/01/2022
• SEYMOUR, PAUL — adp of the snf, NOT APPLICABLE, since 01/01/2022
• SEYMOUR, PAUL — corporate director, NOT APPLICABLE, since 01/01/2022
• VELDT, AMY — operational/managerial control, NOT APPLICABLE, since 01/01/2007
• VELDT, AMY — adp of the snf, NOT APPLICABLE, since 01/01/2007
• VORPAGEL, EARL — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• VORPAGEL, EARL — corporate director, NOT APPLICABLE, since 01/01/2024
• VORPAGEL, EARL — adp of the snf, NOT APPLICABLE, since 01/01/2024
• BAY AREA LUTHERAN HOMES INC — 5% or greater direct ownership interest, 100%, since 11/14/2006
• BMO BANK NATIONAL ASSOCIATION — 5% or greater security interest, NOT APPLICABLE, since 08/12/2021
• BMO BANK NATIONAL ASSOCIATION — adp of the snf, NOT APPLICABLE, since 04/30/2026
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 04/30/2026
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• GREENFIELD REHABILITATION AGENCY, INC — operational/managerial control, NOT APPLICABLE, since 06/01/2019
• GREENFIELD REHABILITATION AGENCY, INC — adp of the snf, NOT APPLICABLE, since 04/30/2026
• HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INC — adp of the snf, NOT APPLICABLE, since 04/30/2026
• HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INC — operational/managerial control, NOT APPLICABLE, since 06/29/2017
• NICOLET NATIONAL BANK — 5% or greater security interest, NOT APPLICABLE, since 04/01/2024
• NICOLET NATIONAL BANK — adp of the snf, NOT APPLICABLE, since 04/30/2026
• PINNACLE INNOVATIVE HEALTHCARE SOLUTIONS, LLC — adp of the snf, NOT APPLICABLE, since 04/30/2026
• PINNACLE INNOVATIVE HEALTHCARE SOLUTIONS, LLC — operational/managerial control, NOT APPLICABLE, since 01/01/2007
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 04/30/2026
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 10/20/2013