Overall sentiment across the reviews is mixed but leans toward concern, with strong polarization between positive impressions of the physical facility and direct caregivers and serious complaints about staffing, management, safety, and operations. Many reviewers praise the building itself — describing it as newer, modern, clean, spacious, and well-laid-out with wide hallways, accessible bathrooms, pleasant natural light, and comfortable common areas including a front patio. Several reviewers explicitly call the facility beautiful and note that housekeeping and overall cleanliness are excellent. The rural/country setting and hospice services are also seen as positives by some families.
However, a major and recurring theme is chronic understaffing and extremely high turnover among both direct care staff and leadership. Reviews describe multiple directors over short time spans (four directors in seven months in one report), frequent staff departures, and owners or management rarely present on-site. Staff are frequently described as overworked, taking on extra duties (caretakers doing food service, laundry, or housekeeping), and paid low starting wages. Several reviewers say the facility has actively eliminated positions such as activity aides and dietary aides as cost-cutting measures, which has degraded service capacity. While many reviewers note that individual caregivers “did their best” and are caring, others report poorly trained or unqualified staff, inconsistent quality of caregiving, and examples of neglect.
Management and governance concerns appear frequently. Multiple reviewers call ownership or management “money-driven” and point to cost-cutting decisions (eliminating aides, reduced staffing) that have compromised resident care. There are mentions that owners monitor via cameras rather than providing consistent hands-on leadership, and several reviewers cite a lack of oversight. Where leadership changes or an RN/director were replaced, some families noted measurable improvements, indicating leadership stability directly affects care quality.
Safety and clinical response raise significant red flags in a number of reviews. Specific incidents include falls with head injuries, delayed or inadequate medical evaluation after incidents, failures to notify family members, prolonged hospitalization, and at least one death several months after an injury. Reviewers report slow responses to call buttons—particularly on weekends—and general lapses in communication after emergencies. These patterns suggest systemic weaknesses in protocols for fall response, family notification, and weekend staffing coverage.
Dining and nutrition are inconsistent across reviews. Several families report poor food quality: warmed-up dinners, limited menu choices (one reviewer said only fish was offered at times), small portions, and a lack of fresh vegetables. Some reviews explicitly call for a full-time cook. Conversely, other reviewers praise the meals and mention an experienced head chef with a restaurant background, so dining experience appears highly variable and may correlate with staffing changes or management decisions.
Activities and social programming are another uneven area. Multiple reviews note that the activities program has been unstable due to staff changes and elimination of activity aides. Some reviewers say the activities director left and programming suffered; others note activities happening several times per week, outdoors during COVID, or that some residents are uninterested in activities. This variability points to program fragility tied to staffing and leadership continuity.
Housekeeping and maintenance are generally positive but not uniform: many reviewers compliment cleanliness and housekeeping staff, while some report inconsistent in-room housekeeping or laundry shortages when staffing is low. A few reviewers mentioned outdated carpeting or small, hospital-like rooms and would have preferred a different room layout (separate bedroom and sitting area).
Security and trust issues also appear: while indoor locks are viewed as keeping residents safe, there are reports of theft and past staff misconduct that undermine family confidence. The combination of theft reports and camera monitoring mentioned by owners hints at reactive surveillance rather than proactive managerial presence.
Recommendations and overall impression are split. Several reviewers explicitly recommend the facility, praising friendliness and specific caregivers, noting improvements after leadership changes, and saying residents have everything they need. Other reviewers strongly advise against the facility, citing poor management, unsafe clinical practices, neglected falls, terrible meals, and staff shortages. A recurring qualifier is to “visit at off times” to see true operations — many families believe the facility looks good on tours but performs differently during regular shifts.
In summary, Bay Harbor Memory Care and Assisted Living of DeForest appears to offer an attractive physical environment and has caring staff in many instances, but systemic issues with staffing levels, leadership stability, operational cuts (especially to activity and dietary support), and clinical/emergency response have created significant and legitimate family concerns. The most consistent areas for improvement identified in reviews are: stabilizing leadership and frontline staffing (including restoring activity and dietary aides), improving emergency response and family communication protocols, addressing meal quality and menu variety, ensuring consistent housekeeping and laundry services, and rebuilding trust after incidents of theft or misconduct. Where management intervened and staffing/leadership stabilized, reviewers reported noticeable improvements, indicating that corrective action can lead to better outcomes; conversely, where cost-cutting and turnover persist, families report declining care and safety risks.
