Overall sentiment across the reviews for Beautiful Savior Nursing Home is highly mixed and strongly polarized. Many reviewers praise individual caregivers, hospice collaboration, and specific programs (notably the exercise/activity director and certain dining accomplishments), while a significant portion report serious problems with staffing, cleanliness, safety, communication, and management responsiveness. The most common theme is inconsistency: several families describe compassionate, skilled, and dedicated staff who went above and beyond during end-of-life care and rehabilitation, while others describe neglectful or rude employees, missed care, and unsafe conditions. These contrasting experiences appear to coexist within the same facility and often vary by shift, unit, or timeframe.
Care quality and staffing: A major positive thread is that the facility has clinical strengths — reviewers frequently mention skilled nursing, experienced long-tenured staff members, effective teamwork with hospice, and good rehabilitation services. Multiple families report respectful, dignified, and sensitive end-of-life care and note that nurses and aides sometimes knew residents by name and provided attentive, compassionate care. On the negative side, numerous accounts describe insufficient staffing, especially nights and weekends, leading to long waits for assistance, unanswered call buttons, residents left in soiled clothing or in distress, delays in showers and basic hygiene, and even incidents where residents were found naked or incontinent. Several reviewers reported medication problems — missed doses, paramedics questioning medication status, or residents being heavily medicated — and other safety concerns such as unreported falls and bedsores. These reports suggest staffing inconsistencies that materially affect resident safety and dignity.
Staff behavior and management: Reviews repeatedly emphasize uneven staff behavior and mixed management responsiveness. Many comments praise individual caregivers and name staff who were helpful, compassionate, and professional. Conversely, there are multiple reports of rude or unprofessional staff, staff talking badly to residents, smoking near residents, staff taking simultaneous breaks that left residents unattended, and at least one report of staff using derogatory language about a resident. Administrative issues surface frequently: families mention rushed check-ins, poor intra-staff communication, unhelpful or defensive management, delayed or missing notifications to power-of-attorney (POA), billing disputes, and failure to respond adequately to complaints. Some reviewers specifically call out an unresponsive or indifferent director of nursing (DON) or administrator, while others note the administrator was accessible and a nurse by training. This split reinforces the overall picture of inconsistent leadership and culture.
Facilities and cleanliness: Physical condition and cleanliness are another area of stark contrast. Several reviews describe freshly painted, well-furnished rooms, orderly common areas, and responsive maintenance. At the same time, many families report serious sanitation problems: bugs and ants in beds and rooms, black mold in vents, days-old urine odors, strong offensive smells, and general filth in parts of the building. Some reviewers state that housekeeping is excellent, while others say cleaning is infrequent and inadequate. The building itself is repeatedly described as older (built in 1969) and in need of cosmetic updates or a 'facelift,' with plastic dressers and dated decor called out. Reports of belongings disappearing and wounds or injuries not being reported add to the safety and trust concerns tied to facility upkeep and oversight.
Dining and activities: Dining receives predominantly positive mentions from many reviewers — good or outstanding food, home-cooked meals, flexible dining hours, and cafeteria staff who accommodate visiting families are commonly praised. The facility's exercise/activities program and a highly regarded exercise director, along with offerings like bingo, crafts, chapel services, and special events, are important positives for many residents. However, other reviewers counter that meals can be poor (limited choices, undercooked or frozen items, lack of fresh fruit, or snack-only options), and that promised structured activities are sometimes absent or not suitable for residents with impairments (e.g., vision issues). This again reflects variability in daily operations and programming.
Safety, incidents, and regulatory issues: Several reviews allege more severe problems such as unreported falls, bedsores, failure to follow physician orders, and even regulatory deficiencies noted by health department inspections. A few reviewers explicitly advise researching inspection histories or even warn the facility should be shut down, while others say the facility is a valued community pillar and would recommend it. These highly divergent assessments underscore a real risk pattern: when care lapses occur, they appear to be significant and potentially harmful.
Patterns and likely explanations: The reviews suggest that positive experiences are often linked to particular staff members, shifts, or teams (including hospice partnerships), whereas negative experiences cluster around under-staffed times, management lapses, or certain units. Problems reported repeatedly — missed medications, long response times at night, theft, infestation, inconsistent housekeeping, and gaps in management follow-up — point to systemic operational issues rather than isolated interpersonal failings. At the same time, the presence of dedicated, long-standing staff and specific strengths (clinical nursing, hospice coordination, dining and activities in some units) indicate there are meaningful assets to the home that could be leveraged with stronger oversight.
Bottom line and suggestions for prospective families: Beautiful Savior Nursing Home offers a mix of notable strengths (compassionate caregivers, solid hospice collaboration, strong rehab and activity programs in some cases, and good dining reported by many) and critical weaknesses (staffing inconsistencies, serious cleanliness and safety complaints, poor communication, and management responsiveness issues). Prospective residents and families should weigh these polarized reports carefully: if considering placement, visit in person at multiple times (day, evening, weekend), ask about overnight staffing ratios and call-button response metrics, review recent state inspection reports and complaint histories, inquire about theft and infection-control procedures, clarify medication management and emergency notification policies, and speak directly with families of current residents about night and weekend experiences. For the facility, the recurring themes indicate focused improvement opportunities: stabilize staffing (especially at night/weekends), strengthen incident reporting and family communication, address cleanliness and pest-control issues, and resolve billing/administrative concerns to rebuild trust.
