Inspection Reports for
Golden Harbor
505 S Water St, Sheboygan, WI 53081, United States, WI
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
36 residents
Based on a August 2025 inspection.
Occupancy over time
Inspection Report
Monitoring
Census: 36
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
Surveyors conducted a monitoring visit and one complaint investigation at Golden Harbor.
Complaint Details
One complaint was investigated and found to be unsubstantiated.
Findings
No deficiencies were identified during the survey, and the one complaint investigated was found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
A complaint investigation was conducted on June 24, 2025, to determine if Golden Harbor LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The complaint investigation was concluded on June 24, 2025, and resulted in findings of noncompliance leading to issuance of a Statement of Deficiency. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #K7U811) 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 applicable requirements within 45 days.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Posting duration: 90
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: 37
Deficiencies: 3
Date: Jun 24, 2025
Visit Reason
Surveyors investigated 6 complaints at Golden Harbor LLC, with two complaints substantiated and three new deficiencies identified, including one repeat violation.
Complaint Details
Six complaints were investigated; two were substantiated. The investigation included an injury of unknown origin not reported to the department and frequent falls experienced by Resident 1.
Findings
The investigation found failures in reporting an injury of unknown origin to the department, failure to update the individual service plan after resident falls, and inadequate documentation of medication administration.
Deficiencies (3)
Failure to report an investigation of an injury of unknown origin to the department for Resident 1.
Failure to update the individual service plan after changes in Resident 1's condition following two falls within a three-day period.
Failure to ensure documentation of medication administration for Resident 2.
Report Facts
Complaints investigated: 6
Complaints substantiated: 2
New deficiencies identified: 3
Resident census: 37
Falls experienced by Resident 1: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Operations A | Regional Director of Operations | Interviewed regarding the injury investigation and individual service plan updates. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
A complaint investigation was conducted on January 16, 2025, to determine if Golden Harbor 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 with applicable statutes and administrative codes.
Findings
The Department issued a Statement of Deficiency (SOD #P63I11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a Notice of Violation, Special Orders to comply within 45 days, and a forfeiture of $600.
Deficiencies (1)
Failure to ensure all habitable floors have at least 2 grade level or ramped exits to grade with cleared, hard surface, barrier-free walkways.
Report Facts
Forfeiture amount: 600
Reduced forfeiture amount: 390
Compliance timeframe: 45
Forfeiture 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: 38
Deficiencies: 3
Date: Jan 16, 2025
Visit Reason
The surveyor investigated one complaint alleging inadequate care and supervision of a resident. The complaint was substantiated and resulted in identification of three new deficiencies.
Complaint Details
The complaint was substantiated. Resident 1 was found in unsanitary conditions with inadequate assistance despite frequent checks and documented care needs. Guardian B reported lack of caregiver response to call lights and delayed assistance.
Findings
The inspection found that the facility lacked required heat detectors in laundry rooms, did not provide two ramped exits to grade as required, and failed to ensure adequate care and supervision for Resident 1, who was found soiled and neglected despite frequent checks and assistance needs.
Deficiencies (3)
Laundry rooms were not equipped with required heat detectors; only smoke detectors were present.
The building did not provide two unobstructed exits that were ramped to grade; only the main entrance was ramped.
Resident 1 did not receive adequate care and supervision, was found lying in urine-soaked bedding with soiled briefs, and assistance needs were unmet despite frequent checks.
Report Facts
Census: 38
Deficiencies identified: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed during inspection; acknowledged deficiencies and care issues |
| Guardian B | Interviewed regarding Resident 1's care; assisted Resident 1 during inspection |
Inspection Report
Follow-Up
Census: 37
Deficiencies: 1
Date: Nov 8, 2024
Visit Reason
Surveyor conducted a verification visit at Golden Harbor for Statement of Deficiency (SOD) 7JQM11 dated 04/30/2024 and SOD VE6I11 dated 02/14/2024.
Complaint Details
One complaint was unsubstantiated.
Findings
Seven deficiencies were identified and all seven were marked as corrected. No new deficiencies were identified. One complaint was unsubstantiated.
Deficiencies (1)
Seven deficiencies identified in prior surveys
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation and self-report review to determine if Golden Harbor LLC was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, concluding a complaint investigation and self-report review to assess compliance with Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83. The Department issued a Statement of Deficiency as a result.
Findings
The Department issued a Statement of Deficiency (SOD #7JQM11) for violations of Wisconsin statutes and administrative codes related to the operation of the facility, establishing grounds for enforcement action and requiring compliance.
Report Facts
Compliance timeframe: 45
Inspection fee: 200
Appeal timeframe: 10
Posting duration: 90
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: 37
Capacity: 40
Deficiencies: 6
Date: Apr 25, 2024
Visit Reason
Surveyors conducted two complaint investigations and reviewed two self-reports at Golden Harbor, triggered by complaints and self-reports, resulting in substantiated complaints and deficiencies.
Complaint Details
Two complaints were substantiated out of two investigated, resulting in six deficiencies.
Findings
The facility was found deficient in multiple areas including failure to conduct annual assessments and update service plans for residents self-administering medications, lack of physician orders and secure storage for self-administered medications, unsanitary food storage and kitchen conditions, unsafe and unclean environment with mold and maintenance issues, and lack of privacy locks on shared bathroom doors.
Deficiencies (6)
Failure to ensure each resident's needs and abilities were assessed at least annually or upon change for Resident 4.
Failure to review and revise the individual service plan annually or on change of condition for Resident 3.
Failure to have physician orders identifying Resident 3's capacity to self-administer medications and failure to provide secure medication storage.
Failure to maintain food safety: freezer temperatures not maintained at 0°F or below, unsealed food items, unsanitary kitchen environment.
Failure to provide a safe, clean, comfortable, and homelike environment: mold, water damage, damaged walls, dirty floors, loose grab bars, and other maintenance issues.
Failure to ensure bathroom doors had locks to ensure privacy in shared bathrooms.
Report Facts
Deficiencies cited: 6
Census: 37
Total Capacity: 40
Freezer temperature: 6
Freezer temperature range: 3
Freezer temperature range: 9
Resident admission date: May 14, 2020
Assessment date: Sep 17, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding medication assessments, kitchen conditions, maintenance issues, and bathroom privacy. |
| Regional Manager B | Regional Manager | Interviewed regarding medication assessments, kitchen conditions, maintenance issues, and corrective actions. |
| Cook C | Cook | Interviewed and observed during kitchen inspection regarding food safety and freezer temperatures. |
| Maintenance D | Maintenance Staff | Mentioned in relation to pipe condensation and repair tasks. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
A complaint investigation and self-report review were conducted on February 14, 2024, to determine if Golden Harbor 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 self-report review. The Department found violations leading to issuance of a Statement of Deficiency. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD #VE6I11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, indicating noncompliance with regulatory requirements for the facility's operation.
Report Facts
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Posting duration: 90
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: 35
Deficiencies: 1
Date: Feb 13, 2024
Visit Reason
An investigation into 4 complaints and a self-report was conducted on 02/13/2024. Two of the 4 complaints were substantiated with 1 deficiency identified related to bed bugs in resident rooms.
Complaint Details
Investigation was conducted in response to 4 complaints and a self-report. Two complaints were substantiated with one deficiency identified. No concerns were found with the self-report.
Findings
The provider did not ensure a safe environment for 3 residents who had bed bugs found in their rooms from 02/07/2024 to 02/12/2024. Residents slept and ate in these rooms despite the known presence of live bed bugs. Pest control treatment was conducted on 02/12/2024 with a follow-up scheduled.
Deficiencies (1)
The provider did not ensure a safe environment for 3 residents who had bed bugs in their rooms from 02/07/2024 to 02/12/2024.
Report Facts
Complaints investigated: 4
Complaints substantiated: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | ADM - A confirmed pest control inspection and actions | |
| Regional Manager | RM - B confirmed pest control inspection and resident information |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
Surveyors investigated one complaint at Golden Harbor LLC.
Complaint Details
Complaint was unsubstantiated with no new deficiencies identified.
Findings
The complaint was unsubstantiated and no new deficiencies were identified.
Inspection Report
Follow-Up
Census: 40
Deficiencies: 0
Date: Oct 4, 2023
Visit Reason
Surveyor conducted a verification visit and investigated one complaint to determine compliance and correction of previous deficiencies.
Complaint Details
Complaint was investigated and found to be unsubstantiated.
Findings
Five out of five previous deficiencies were corrected. The complaint was unsubstantiated and no new deficiencies were identified.
Report Facts
Revisit fee: 200
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 7, 2023
Visit Reason
A standard survey and complaint investigation were conducted to determine if Golden Harbor 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; substantiation status is not explicitly stated.
Findings
The Department issued a Statement of Deficiency (SOD #Z99X11) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a notice of violation and an imposed forfeiture.
Report Facts
Forfeiture amount: 520
Reduced forfeiture amount: 338
Forfeiture payment timeframe: 10
Compliance timeframe: 45
Extension request timeframe: 10
Appeal request timeframe: 10
Inspection fee: 200
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: 37
Capacity: 40
Deficiencies: 5
Date: Apr 4, 2023
Visit Reason
Surveyors conducted a standard survey and seven complaint investigations at Golden Harbor. Two of the seven complaints were substantiated, resulting in two deficiencies, with three additional deficiencies identified during the standard survey.
Complaint Details
Seven complaint investigations were conducted; two complaints were substantiated resulting in two deficiencies. The complaint related to medication administration was substantiated.
Findings
Five total deficiencies were identified, including failure to report incidents of serious injury within three working days, failure to ensure residents received all prescribed medications, unsafe environment due to moldy pipe, unlocked medication storage, and inadequate safeguarding of resident records.
Deficiencies (5)
Provider did not send a report to the department within three working days after an incident resulting in serious injury requiring hospital admission for one resident.
Provider did not ensure Resident 1 received all prescribed medication as ordered, with multiple documented missed administrations.
Provider did not ensure the environment was safeguarded from hazardous conditions, evidenced by a moldy PVC pipe in the pantry.
Provider did not keep all medications locked, with an unlocked medication storage room and refrigerator containing medications.
Provider did not ensure resident records were adequately safeguarded against destruction, loss, or unauthorized access, with unlocked storage room and file cabinet containing sensitive records.
Report Facts
Total deficiencies identified: 5
Number of complaints investigated: 7
Number of substantiated complaints: 2
Facility licensed capacity: 40
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director A | Regional Director | Interviewed regarding incident reporting, medication administration, mold observation, medication storage, and record safeguarding |
| Administrator B | Administrator | Interviewed regarding mold observation, medication storage, and record safeguarding |
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