Overall sentiment: The reviews for Stonehedge Rehabilitation and Skilled Care Center are overwhelmingly negative with recurring, serious concerns about cleanliness, staffing, safety, and clinical care. While a minority of reviewers single out individual staff members and specific departments (notably certain therapists, a resident ambassador, and named nursing leaders) for high-quality, compassionate care, the dominant pattern across reviews is one of neglect, poor infection control, and systemic operational failures.
Care quality and clinical issues: Multiple reviews allege medication errors, medicines withheld, antibiotics stopped prematurely, and general cavalier attitudes toward medication management. There are repeated accounts of delayed medical attention, failure to promptly contact EMS, and poor communication with families. Several reviewers report residents deteriorating (including becoming bedridden or stopping eating) while at the facility, and at least one review links such care issues to a resident death. Feeding assistance is often inadequate due to staffing shortages, and reviewers describe residents being left in urine, ignored during toileting and bedpan needs, or otherwise neglected in basic personal care. These clinical and care-delivery concerns are among the most serious themes in the dataset.
Staffing, behavior, and interpersonal interactions: Staffing levels and staff behavior are highly inconsistent. Many reviews describe understaffing (especially overnight), unresponsive or slow staff, angry or rude CNAs, and instances of verbal abuse or rough handling. Conversely, several specific staff members receive strong praise: the Director of Nursing (Victoria R.) is repeatedly described as caring, knowledgeable, and hands-on; a resident ambassador (Mirian / Miriam De Souza) is frequently called supportive and positive; some nurses (e.g., Alitane Olivier) and therapy teams (PT/OT) are praised for competence and responsiveness. This creates a stark contrast: pockets of compassionate, effective care exist, but they are offset by broad reports of inattentive or abusive staff and insufficient staffing to meet resident needs.
Facilities, cleanliness, and safety: A dominant and disturbing theme is the facility’s physical condition and infection/control problems. Numerous reviewers mention cockroaches, mice, rats, ants, filthy hallways and bathrooms, pervasive foul smells, unmade beds, and overall squalid conditions. Structural and maintenance issues are also noted: rooms smell of feces, heat failing, bathrooms flooding overnight without timely repair, the building shaking when trucks pass, and a shared bathroom layout in at least one area with only one toilet/sink. Safety equipment concerns include reports of oxygen equipment batteries being dead and staff lying about smoking while on oxygen. Taken together, these observations point to lax environmental maintenance practices and potential infection-control risks.
Dining and nutrition: Dining reviews are very mixed but lean negative. Several reviewers report inedible or stale food, improper storage of meals, and at least one alleged food-poisoning incident. Others praise the kitchen staff and describe the food as good or a favorite, indicating variability in meal quality or in different units/shifts of the facility. However, combined with reports of inadequate assistance with feeding, the dining experience is a clear area of concern for residents who need help eating.
Management, communication, and organizational issues: Reviewers frequently cite poor communication from management, case managers being unavailable (e.g., on vacation when families needed them), and turnover among administration. Some family members describe difficulty getting timely updates or involvement in care decisions, and there are allegations of mishandling of DNR directives and end-of-life communication. A few reviews counter this with statements that the administrator and DON were responsive in specific cases, again underscoring inconsistent leadership performance.
Patterns, polarization, and notable positives: The reviews reveal a polarized experience—some families and residents report genuinely compassionate caregivers, effective rehabilitation, dependable laundry/housekeeping staff, and a welcoming environment, while many more describe systemic failures. The most consistently praised elements are certain individual staff members (the DON Victoria R., Miriam De Souza, select nurses, and some therapy teams). These positives suggest that pockets of good practice and staff dedication exist, but they appear insufficient to overcome pervasive operational and environmental problems reported by numerous reviewers.
Severity and risk implications: The combination of alleged neglect (lack of toileting assistance, delayed feeding), medication errors, infection-control failures (infestations, filth), and slow emergency response creates a pattern that could compromise resident safety and wellbeing. Multiple reviewers explicitly urge others to avoid the facility, and some characterize it as a place where residents "deteriorated" or died. Even where positive staff are noted, reviewers repeatedly say the facility overall "should be closed" or is a "dumping ground," reflecting severe distrust.
Conclusion and considerations for families: Families should treat these reviews as signaling significant risk factors. If considering Stonehedge, families should verify up-to-date information about staffing ratios, infection-control practices, medication management protocols, emergency response procedures, and recent health inspection reports. Ask facility leadership about turnover, how they address infestations and maintenance, how they ensure consistent feeding and toileting assistance, and how they handle medication administration and end-of-life directives. Also consider meeting and documenting interactions with the specific staff members repeatedly praised (e.g., DON Victoria R., Miriam De Souza, named nurses/therapists) to understand whether their presence is stable and whether their practices are supported by facility-wide policies.
Overall, while individual staff members and some departments receive strong praise, the volume and severity of negative reports—particularly around cleanliness, staffing, medication safety, and emergency responsiveness—are substantial and recurring. These issues warrant careful scrutiny by any family considering placement and likely require corrective action and oversight by facility management and regulators to ensure resident safety and dignity.
