Inspection Reports for Woodside Lutheran Home
1040 PILGRIM WAY, GREEN BAY, WI, 54304
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 1
Date: Sep 24, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically to determine if the facility established and maintained appropriate measures to prevent the development and transmission of communicable diseases and infections.
Findings
The facility failed to implement Enhanced Barrier Precautions (EBP) for one resident with an indwelling urinary catheter. Staff did not wear the required gown during high-contact care, such as catheter care, contrary to the facility's policy.
Deficiencies (1)
Failure to implement Enhanced Barrier Precautions (EBP) including gown use during catheter care for a resident with an indwelling urinary catheter.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-C | Certified Nursing Assistant | Observed not wearing a gown during catheter care in violation of facility's EBP policy. |
| DON-B | Director of Nursing | Interviewed and confirmed that gown use is required during catheter care as per facility policy. |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 31, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage and administration policies, focusing on proper labeling, dating, and disposal of medications and medical supplies in the facility.
Findings
The facility failed to ensure that medications and medical supplies were properly labeled, dated, and stored. Multiple expired, undated, unlabeled, and improperly stored medications and supplies were found across medication carts, treatment carts, and medication rooms. Staff interviews confirmed these deficiencies and acknowledged that expired items should have been discarded.
Deficiencies (5)
Medications for 11 residents in multiple medication and treatment carts were not stored, labeled, and/or dated appropriately.
Expired alcohol wipes, sterile syringes, and other medical supplies were stored in medication rooms and not discarded.
Multiple medications including inhalers, nasal sprays, insulin pens, and topical treatments were open, undated, unlabeled, or expired.
Syringes with different expiration dates were stored together, including expired syringes.
Expired wound dressings, alcohol prep pads, and other topical products were found in medication storage areas.
Report Facts
Residents affected: 11
Medication carts inspected: 8
Treatment carts inspected: 5
Expired chlorhexidine cloth packages: 4
Expired lubricating jelly packets: 59
Expired syringes: 2
Medication expiration days: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-I | Licensed Practical Nurse | Observed administering medication and verified missing open dates on medication packages |
| RN-G | Registered Nurse | Verified expired items in medication storage and treatment carts |
| NM-H | Nurse Manager | Confirmed expired items should have been discarded |
| LPN-F | Licensed Practical Nurse | Interviewed regarding observations of syringes with different expiration dates and unlabeled items |
| NM-C | Nurse Manager | Interviewed and verified expired medications should be discarded and proper labeling required |
| RN-D | Registered Nurse | Confirmed unlabeled and expired items on Rehab Unit |
| RN-E | Registered Nurse | Confirmed expiration dates and missing open dates on medication storage items |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Woodside Lutheran Home following a survey completed on 06/28/2023.
Findings
No health deficiencies were found during the survey.
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