Overall sentiment in the reviews is strongly mixed, with a clear pattern of polarized experiences. Many families and residents describe compassionate, skilled, and familial care — particularly from therapy teams and several named staff members — while others recount serious lapses in basic nursing care, safety, and management responsiveness. The result is a facility that, according to reviewers, can provide excellent rehabilitation and warm personal attention in some cases but also can fail to meet essential care standards in others.
Care quality shows contrasting themes. On the positive side, multiple reviewers credit the facility with strong physical and occupational therapy, rehabilitation successes that restored independence, and individual staff who went above and beyond. Several accounts highlight attentive nursing, good wound/rehab follow-through in certain cases, effective discharge planning, and peaceful, dignified end-of-life care. Conversely, a large cluster of complaints focuses on medication mismanagement (meds given late, not logged, missing from carts, or nurses logging times retrospectively), basic hygiene neglect (showers infrequently provided, sometimes only a single bath in a long stay), oxygen and wound-care concerns, dehydration and lack of water, and incidents that led to ER visits or hospital admissions. These are serious clinical issues that appear repeatedly in reviews and contribute to a reputation for unsafe care for some residents.
Staffing and behavior patterns are another major theme. Many reviewers praise individual employees — including physical therapists and specific nurses or social workers — and note courteous housekeeping and a friendly atmosphere. However, there are persistent reports of problematic staff conduct, often concentrated on night and evening shifts: cursing at patients, alleged sleeping or napping in unoccupied rooms, excessive smoking breaks (including use of fire exits), rude or lazy behavior by some CNAs, and at least one report of an RN passing out. Reviewers frequently draw a distinction between daytime/therapy staff and night/weekend staff, implying inconsistent standards and supervision across shifts. Several comments explicitly single out CNAs as a weak point while lauding therapy staff and some LPNs/RNs.
Safety, incidents, and management communication are recurring concerns. Multiple reviewers report resident falls, injuries, and alleged staff-caused harm that required hospital transfers. There are also serious allegations of theft and concealment of information, with families describing unresponsive leadership, ignored calls, and welfare-checks not acted on. Some reviewers accuse the facility of prioritizing profit or obfuscating problems; others describe being unable to obtain receipts or clear documentation for payments. While these are allegations and some families express confidence in specific members of the team, the volume and severity of these complaints indicate systemic communication and oversight weaknesses that prospective families should probe.
Facilities, dining, and activities receive mixed feedback. Many reviewers appreciated the clean appearance, courteous housekeeping, and three hot meals daily, with several specific commendations for the dietary team and enjoyable food. Conversely, some residents reported poor-tasting or weak meals, hard beds, and a generally rundown feel in places. Activity programming receives positive notes, with at least one family saying that a resident enjoyed time with the activity director, suggesting available social engagement for some residents. Access and logistics problems are also mentioned: transportation to outside appointments is frequently mismanaged, resulting in missed or rescheduled specialist visits, and weekend staffing shortages can create difficulties for visitors and intake procedures.
Patterns and interpretation: the reviews indicate wide variability in experience that likely stems from inconsistent staffing, differential management oversight across shifts, and possible turnover or gaps in training. The most consistent positives are strong therapy services, some compassionate and dependable staff members, and cases of excellent rehabilitation and end-of-life care. The most consistent negatives are medication and documentation errors, hygiene neglect, night-shift behavior problems, communication failures with families, and reports of serious safety incidents including falls, dehydration, and alleged theft. Because both highly positive and highly negative experiences are common, the facility appears to perform well for some residents but not reliably for all.
For prospective residents or families, these reviews suggest several practical points to verify directly with the facility: medication management and documentation procedures, staffing levels and supervision during nights and weekends, showering/hygiene schedules, transportation and appointment coordination, security measures for personal belongings, and how the facility handles family communications and incident reporting. The mixed nature of feedback highlights that individual unit culture, specific caregivers, and shift-to-shift consistency will strongly influence any given resident's experience at Legacy Health and Rehabilitation of Pleasant Grove, LLC.
