Inspection Reports for Bayview Senior Care LLC
839 S 18th Ave, Sturgeon Bay, WI, 54235-1557
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 10, 2025, found deficiencies related to resident care, dietary compliance, food safety, and adequate care provision, resulting in a $2,450 forfeiture. Earlier inspections showed a pattern of issues including inadequate staffing and supervision, health monitoring failures, cleanliness concerns, and safety problems such as resident elopements and medication storage. Complaint investigations often substantiated deficiencies involving resident care, safety, and environmental conditions, with fines imposed but no license suspensions or immediate jeopardy findings listed in the available reports. Most complaints were substantiated, including notable cases of resident elopement and delayed medical care leading to hospitalizations. The inspection history indicates ongoing challenges with care and safety standards, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
47 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 4
Date: Sep 10, 2025
Visit Reason
Surveyors conducted a complaint investigation at Bayview Senior Care LLC following complaint information alleging resident care needs were not being met.
Complaint Details
Complaint investigation triggered by allegations that resident care needs were not being met. The complaint was substantiated with multiple care deficiencies found.
Findings
The complaint was substantiated with four deficiencies identified related to failure to assess residents after changes in condition, failure to follow special dietary needs, failure to maintain food safety temperatures, and inadequate care resulting in negative outcomes including weight loss, skin impairment, and safety concerns for two residents.
Deficiencies (4)
Failure to assess Resident 1 and Resident 2 when there was a change in needs, abilities, or condition.
Failure to follow Resident 2's special dietary needs as ordered by physician; Resident 2 was served popcorn despite requiring a pureed diet.
Failure to hold hot foods at 140°F or above for 15 of 47 residents; observed food temperatures were below safe levels.
Failure to provide adequate and appropriate care to Resident 1 and Resident 2 including morning cares, autonomy, meal service, repositioning, toileting, catheter care, skin care, safety checks, and housekeeping.
Report Facts
Census: 47
Weight loss Resident 1: 39
Weight loss Resident 2: 20
Food temperature: 96.8
Food temperature: 96
Food temperature: 97.6
Safety checks documented: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN I | Hospice Registered Nurse | Interviewed regarding Resident 1's catheter care and skin condition |
| POAHC G | Power of Attorney for Healthcare | Expressed concerns about Resident 1 and Resident 2 care and catheter use |
| Attendant F | Observed feeding residents and serving food including popcorn to Resident 2 | |
| Caregiver E | Observed assisting residents and feeding Resident 2 | |
| LPN D | Licensed Practical Nurse | Observed during morning cares and interviewed about Resident 1 care |
| Assistant Director B | Assistant Director | Interviewed regarding weight loss concerns and food service |
| Regional Director A | Regional Director | Interviewed and acknowledged Resident 1 and Resident 2 needs were not met |
| Director of Nursing C | Director of Nursing | Interviewed and acknowledged Resident 1 and Resident 2 needs were not met |
| Family Member J | Interviewed expressing concerns about Resident 2's care and room condition | |
| Hospice RN Q | Hospice Registered Nurse | Provided wound care notes for Resident 1 |
| Hospice Director of Quality and Compliance R | Hospice Director of Quality and Compliance | Interviewed about catheter use and repositioning recommendations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 10, 2025
Visit Reason
A complaint investigation was conducted to determine if Bayview Senior Care LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint investigation concluded on September 10, 2025, found violations leading to the issuance of Statement of Deficiency #H03F11. The Department imposed a total forfeiture of $2,450.00 for specific violations detailed in the SOD.
Findings
The Department issued a Statement of Deficiency (SOD #H03F11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation and an imposed forfeiture totaling $2,450.00. The licensee is ordered to comply with requirements and implement corrective measures within 45 days.
Report Facts
Forfeiture amount: 2450
Reduced forfeiture amount: 1592.5
Forfeiture breakdown: 800
Forfeiture breakdown: 500
Forfeiture breakdown: 150
Forfeiture breakdown: 1000
Compliance timeframe: 45
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
A verification visit and complaint investigation were conducted on August 13, 2025, to determine if Bayview Senior Care LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, involving a verification visit and complaint investigation to assess compliance with statutory and administrative requirements for community-based residential facilities.
Findings
The Department issued a Notice of Violation and Order to Comply with Requirements due to violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply immediately with staffing requirements and develop written procedures within 45 days. A forfeiture of $2,850 was imposed for the violations, with a reduced forfeiture option available.
Report Facts
Forfeiture amount: 2850
Reduced forfeiture amount: 1852.5
Forfeiture amount: 1450
Forfeiture amount: 1400
Inspection fee: 200
Compliance timeframe: 45
Payment timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 70
Deficiencies: 4
Date: Jul 30, 2025
Visit Reason
Surveyors conducted a verification visit and 5 complaint investigations at Bayview Senior Care LLC due to complaints alleging inadequate staffing, supervision, health monitoring, and cleanliness concerns.
Complaint Details
Five complaints were investigated; three were substantiated including inadequate staffing, supervision, health monitoring, and cleanliness issues.
Findings
The facility was found to have inadequate staffing to meet resident needs, insufficient supervision leading to wandering and residents entering others' rooms, failure to monitor and communicate health changes for residents, and failure to maintain cleanliness and odor control in resident rooms.
Deficiencies (4)
Inadequate staff to meet resident needs with only 2 care staff on many shifts for 50 residents, including those requiring enhanced supervision and assistance.
Inadequate supervision of residents, resulting in wandering, residents entering other resident rooms, and residents feeling unsafe.
Failure to monitor health and communicate with physicians for residents with changing conditions, including failure to assist with scheduling follow-up visits and failure to notify physicians of medication refusals.
Failure to maintain resident rooms clean and free from odors, with observations of urine and feces odors, soiled linens, clutter, and unclean bathrooms.
Report Facts
Residents: 50
Total licensed capacity: 70
Shifts with only 2 care staff: 29
Residents requiring 2-staff assistance: 4
Residents requiring mechanical lifts: 5
Residents requiring sit-to-stand lifts: 3
Residents requiring 30-minute safety checks: 3
Residents requiring 2-hour safety checks: 3
Residents taking longer than 4 minutes to evacuate: 3
Medications held due to low blood pressure: 16
Medication refusals: 11
Care refusals: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J | Director of Nursing | Interviewed regarding staffing, supervision, and resident care issues |
| K | Regional Director | Interviewed regarding staffing, supervision, and resident care issues |
| C | Administrative Coordinator | Interviewed regarding staffing and communication with physicians |
| G | Health Unit Coordinator | Interviewed regarding resident care and communication with physicians |
| P | Dietary Coordinator | Interviewed regarding staffing |
| L | Housekeeper | Interviewed regarding cleanliness and housekeeping issues |
| E | Life Enrichment Coordinator | Interviewed regarding resident behaviors and supervision |
| N | Ombudsman | Interviewed regarding resident supervision and wandering |
| H | Social Worker | Interviewed regarding resident behaviors |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
A complaint investigation was conducted on March 12, 2025, to determine if Bayview Senior Care LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The investigation was complaint-driven and concluded that the facility was not in substantial compliance, resulting in issuance of a Statement of Deficiency and enforcement actions including a forfeiture.
Findings
The Department issued a Statement of Deficiency (SOD #F32B11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements to protect residents' health, safety, and welfare, including developing procedures for door alarm systems and staff training. A forfeiture of $500 was imposed for the violations.
Deficiencies (1)
Violations of Wis. Stat. ch. 50 or Wis. Admin. Code ch. DHS 83 as identified in SOD #F32B11
Report Facts
Forfeiture amount: 500
Reduced forfeiture amount: 325
Forfeiture payment timeframe (days): 10
Compliance timeframe (days): 45
Extension request timeframe (days): 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 70
Deficiencies: 2
Date: Feb 14, 2025
Visit Reason
Surveyors conducted a complaint investigation triggered by concerns about resident elopements and inadequate care at Bayview Senior Care LLC. The investigation included onsite visits on 02/14/2025 and 02/27/2025, and information gathering through 03/12/2025.
Complaint Details
The complaint investigation was initiated due to concerns about resident elopements and inadequate care. Two of three complaints were substantiated. Resident 1 eloped and was found by a citizen near a hospital. Resident 2 was not provided timely care for a UTI, leading to multiple emergency room visits and reports of neglect to Adult Protective Services.
Findings
Two deficiencies were identified: the facility failed to ensure a safe environment preventing resident elopement, and failed to provide adequate and appropriate care to a resident resulting in delayed diagnosis and treatment of a urinary tract infection (UTI).
Deficiencies (2)
The provider did not ensure a safe environment for Resident 1 who eloped from the facility on 01/28/2025 due to malfunctioning front door alarms and inadequate monitoring.
The provider did not ensure Resident 2 received adequate and appropriate care, including failure to obtain a physician-ordered urinalysis in a timely manner, resulting in a significant urinary tract infection and multiple hospitalizations.
Report Facts
Census: 47
Total Capacity: 70
Complaints substantiated: 2
Complaints received: 3
Safety checks frequency: 2
Toileting schedule frequency: 12
Average daily traffic count: 14200
Temperature: 101.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse J | Nurse | Completed Resident 1's pre-admission assessment and assessed Resident 2 |
| Resident Assistant U | Resident Assistant | Observed silencing pager alert and assisted Resident 2; involved in Resident 2 care |
| Health Unit Coordinator G | Health Unit Coordinator | Observed Resident 1 walking halls, reported front door issues, and cared for Resident 2 |
| Caregiver H | Caregiver | Reported issues with pager alerts and front door monitoring |
| Resident Assistant Z | Resident Assistant | Expressed concerns about front door safety and monitoring |
| Regional Director K | Regional Director | Reported front door repairs and facility internal investigation |
| Family Member N | Family Member | Informed facility and emergency services about Resident 2's condition |
| Family Member V | Family Member | Observed Resident 2's soiled bedding and cleaned mattress |
| Licensed Practical Nurse T | LPN | Completed Physician Communication Form ordering UA for Resident 2 |
| Managed Care Organization Care Manager R | Care Manager | Reported concerns of neglect to Adult Protective Services |
| Registered Nurse J | Director of Nursing | Attended meeting regarding Resident 2's care concerns |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
Surveyor conducted a verification visit and investigated 3 complaints at Bayview Senior Care in Sturgeon Bay.
Complaint Details
Three (3) complaints were investigated and all were unsubstantiated.
Findings
All previous deficiencies were corrected, three complaints were unsubstantiated, and no new deficiencies were issued.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
A standard survey and complaint investigation were conducted to determine if Bayview Senior Care LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related and included a standard survey to assess compliance. The report does not specify substantiation status.
Findings
The Department issued a Statement of Deficiency (SOD #I6MI11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, establishing grounds for enforcement action and requiring the licensee to comply with all requirements to protect resident health, safety, and welfare.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Extension request timeframe: 10
Posting duration: 90
Appeal request timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 6
Date: Feb 19, 2024
Visit Reason
On 02/19/2024, surveyors investigated four complaints and conducted a standard survey. Three of the complaints were substantiated and six new deficiencies were identified in total.
Complaint Details
Four complaints were investigated; three were substantiated. Complaints included dirty microwaves, concerns about cleanliness and odors in resident rooms and bathrooms.
Findings
The inspection found multiple deficiencies including unclean kitchen equipment (dirty microwaves), rooms and bathrooms not clean and free from odors, inadequate fire drill documentation, lack of semi-annual disaster evacuation drills, and failure to conduct annual fire detection system inspections.
Deficiencies (6)
Kitchen equipment, specifically microwaves, were not kept clean with dried, splattered food observed on interior surfaces.
Common areas and personal rooms for residents were not clean and had strong odors, including feces odor in resident rooms.
Resident bathrooms were not clean, with feces observed in toilets and on floors in multiple resident bathrooms.
Quarterly fire drills did not include documentation of total evacuation time.
Tornado, flooding, or other emergency evacuation drills were not conducted at least semi-annually; only one drill was completed in 2023.
Fire detection system was not inspected, cleaned, or tested annually since the provider obtained the license in 2022.
Report Facts
Complaints investigated: 4
Complaints substantiated: 3
Deficiencies identified: 6
Census: 41
Resident rooms with unclean toilets: 4
Fire drills missing total evacuation time: 5
Disaster evacuation drills completed in 2023: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director B | Acknowledged findings regarding dirty microwaves, cleanliness and odors in resident rooms and bathrooms, missing fire drill documentation, lack of disaster drills, and fire detection system inspection status. | |
| Caregiver E | Interviewed regarding housekeeping and resident room cleaning refusals. | |
| Compliance Officer A | Interviewed regarding disaster drill requirements and fire detection system inspection. | |
| Director of Nursing C | Interviewed regarding cleanliness and odors in resident rooms and bathrooms. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
A complaint investigation and verification visit was conducted on August 1, 2023, to determine if Bayview Senior Care LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, conducted to verify compliance with regulatory requirements. The report does not state whether the complaint was substantiated.
Findings
The Department issued a Statement of Deficiency (SOD #Z0F912) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The licensee was ordered to comply with requirements immediately and achieve substantial compliance within 45 days.
Report Facts
Inspection fee: 200
Appeal period: 10
Compliance timeframe: 45
Posting duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the notice letter as the Assisted Living Director, Bureau of Assisted Living, Division of Quality Assurance. |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Aug 1, 2023
Visit Reason
The surveyor conducted 3 complaint investigations and a verification visit at Bayview Senior Care LLC, triggered by complaints about medication self-administration and secure storage of medications.
Complaint Details
Three complaints were investigated; one was substantiated regarding lack of secure medication storage for residents self-administering medications.
Findings
One of three complaints was substantiated. The facility did not provide a secured place for the storage of medications for two residents who self-administered their medications, as confirmed by observations and interviews.
Deficiencies (1)
The provider did not provide 2 of 2 residents with a secure way to store medications in their rooms.
Report Facts
Revisit fee: 200
Census: 48
Number of complaints investigated: 3
Number of complaints substantiated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director C | Executive Director | Acknowledged residents did not have medications secured and that a solution was being worked on |
| Assistant Director B | Assistant Director | Identified Resident 2 as able to administer own medications |
| Nurse A | Nurse | Identified Resident 1 as able to administer own medications |
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