Overall sentiment in these reviews is highly polarized but predominately negative, with a large number of detailed complaints describing systemic care, safety, cleanliness, and management problems alongside a smaller but consistent set of very positive experiences pointing to strong pockets of clinical and caregiving excellence.
Care quality and medical management: A recurring and serious theme is inconsistent or unsafe clinical care. Multiple reviewers allege medication mismanagement (including administration of inappropriate psychiatric medications), mishandling of feeding tubes and braces, and documentation issues such as forged signatures. There are repeated reports of falls where appropriate follow-up (X-rays, monitoring, transfer to hospital) was not provided. A few reviewers attributed death or severe deterioration to care received at the facility. Conversely, several reviewers reported outstanding rehabilitation outcomes and top-notch clinical teams who enabled full recovery—this indicates that clinical quality may vary significantly by unit, shift, or individual staff members.
Staff behavior, competency, and dynamics: Reviewers describe two very different staff experiences. Many describe compassionate, attentive nurses and CNAs by name and praise the admissions, social services, activities teams, Director of Nursing and leadership when they are engaged and accountable. However, a large volume of reviews detail rude, unprofessional, argumentative, or unapproachable staff and social workers unfamiliar with legal processes. Multiple reports point to internal cliques, favoritism, nepotism, gossip, and lack of accountability among staff, which reviewers say undermines consistent care. Some extreme safety-related allegations include staff brawls and physical assault by employees, creating acute safety concerns for residents and visitors.
Cleanliness, pests, and facility condition: Cleanliness and facility upkeep are among the most frequent complaints. Many reviews report a pervasive smell of urine, filthy rooms and bathrooms, open urine containers on food trays, dust, dirt, and broken equipment (rusty beds, crank beds, holes in walls, slow/broken elevators). Widespread pest problems (roaches and alleged bed bugs) are mentioned repeatedly. A minority of reviewers, however, say the facility is clean and well-maintained; this mixed feedback suggests serious variability across floors or differences over time.
Nutrition and dining: Dining and nutrition are flagged as problematic in many accounts—missed or delayed meals, residents who were not actually fed despite nurse assertions, and poor food quality. A handful of reviewers describe dining staff positively, but the more numerous reports of missed meals and weight loss are concerning and tied to allegations of neglect.
Therapy, rehabilitation, and activities: Comments on therapy are mixed. Several reviewers praise the rehab teams and activities department, describing meaningful progress and a superior source of healing that enabled transitions back home or into independent apartments. In contrast, other reviews criticize inadequate therapy frequency, disorganized therapy scheduling, and poor coordination between therapists and nursing staff.
Safety, incidents, and infection control: Safety concerns are prominent—reports include residents left unattended, left in urine, unattended feeding leading to aspiration risk, unaddressed falls, allegations of sepsis and serious infections, theft of personal belongings, and slow emergency responses. Staff glove mishandling and lack of supplies (no wipes) were cited as infection control problems. Several reviewers explicitly called for the facility to be shut down or for external/state investigation based on these safety reports.
Management, communication, and policies: Many reviewers describe poor communication, lack of transparency, and disorganized administration—discharge chaos, delayed transfers, and refusal to allow families access have been reported. Social workers and managers are sometimes praised for professionalism and support, but other reviewers reported social workers unfamiliar with legal next-of-kin rules and management that is unresponsive or only nominally present. Reports of restricted visitation, lack of bathing, and inconsistent enforcement of policies fueled calls for outside oversight.
Environment and neighborhood: Multiple reviews mentioned the facility’s location and neighborhood safety concerns (Auburn Ave area) and advised caution visiting at night. Parking constraints and limited handicap spaces were also flagged.
Patterns and variability: The reviews indicate significant variability in experience—some families describe exemplary service and successful rehabilitation with staff who are attentive and professional, while many more describe systemic neglect, unsafe care, and unsanitary conditions. This pattern suggests inconsistent staffing levels, variable training or supervision, or unit-specific management practices that produce widely different resident experiences.
Notable specific allegations: Beyond the broad patterns above, reviewers specifically alleged forged signatures on documents, physical assaults by employees, withholding or poor monitoring after falls, theft of belongings, open urine containers being served with meals, claims of staff dishonesty about whether residents were fed or bathed, and staff brawls affecting resident safety. Named staff received both praise and criticism, illustrating uneven performance across personnel.
Implications and next steps suggested by reviewers: Many reviewers urge investigation and corrective action—pest control, comprehensive cleaning, robust infection control, strengthened medication and documentation practices, better fall follow-up protocols, higher staffing levels or improved response times to call lights, improved staff training (including conflict resolution and empathy), transparent communication with families, and management accountability to address cliques and favoritism. The presence of both very positive and very negative reviews indicates that targeted quality improvement—rather than wholesale dismissal of all staff—could address the inconsistent standards cited. However, the volume and severity of negative reports (unsafe care, violence, infection, and allegations of forgery) support the calls for external review or regulatory attention until reliable, consistent care can be demonstrated.
