Overall sentiment across the reviews is heavily mixed but predominately negative, with multiple reviewers reporting serious hygiene, safety, and care-quality problems. The most frequent and severe themes are unclean living conditions (strong urine odors, roaches, dirty rooms and bathrooms), neglect around personal hygiene (infrequent showers or baths, residents left sitting all day), and inconsistent or unsafe clinical care (delayed or missing medications, oxygen administration concerns, equipment failures). Several reviewers explicitly describe conditions and incidents that raise immediate safety and infection-control concerns.
Facility cleanliness and basic hygiene are a central and recurring complaint. Multiple reviewers reported rooms and bathrooms that were not cleaned for weeks, pervasive urine smells, visible roaches in resident rooms and common areas, lost laundry, old/rusty beds, and ceiling leaks. Bathing frequency was described as inadequate — some said showers occurred only twice in three weeks or that baths were only on specific days (Wednesdays and Saturdays). These recurring descriptions suggest systemic housekeeping and infection-prevention problems rather than isolated lapses.
Medical care and nursing practice concerns are also prominent. Reviews allege delayed pain medication, inconsistent medication administration with records showing meds not given, and nurses reportedly not wearing gloves when administering medications. There are also claims of inadequate oxygen administration and even oxygen deprivation, malfunctioning equipment, and delayed repairs. Some reviewers reported falls and blood, and physical therapy staff not adequately monitoring exercises. Taken together, these items indicate potential lapses in clinical protocols, documentation, staff training, and responsiveness.
Staff behavior and competence show a wide range of experiences. Many reviews describe staff as rude, unprofessional, argumentative, or indifferent — with reports of yelling, staff arguing among themselves, and technicians questioning why a resident was there. Several reviewers raised concerns about CNA qualifications and insufficient staffing levels, noting long waits for assistance (45+ minutes) and residents being left in chairs all day. At the same time, a consistent countertheme is that some staff are excellent: department heads (Director of Nursing and Assistant DON) received praise, certain employees and teams were described as caring and professional, and specific individuals (e.g., a transport driver named Kyle) were singled out as helpful. This pattern suggests significant variability in staff performance and possibly uneven training, morale, or turnover.
Facilities, maintenance, and dining were additional trouble spots. Reviewers reported old, poorly maintained equipment and infrastructure problems such as ceiling leaks and rusty beds. Dining repeatedly received negative comments — described as "horrendous" by multiple reviewers, and one review even mentioned food being withheld. Some reviewers noted remodeling or cosmetic work but said renovations have not addressed core cleanliness and care deficiencies.
Management, oversight, and regulatory issues appear in multiple reviews. Several reviewers described unhelpful or evasive administration responses to complaints, with at least one review mentioning police involvement, a state agency complaint, and even a reported resident death. Conversely, there are several mentions of new management, new ownership, and a stated "new vision for excellence and growth" with some reviewers believing the facility is moving in the right direction. This contrast may indicate a transition period in leadership and operations; however, given the severity of many complaints, the presence of improvement initiatives does not override the immediate, concrete problems reported by families.
There is a clear pattern of inconsistent experiences: some visitors and residents describe clean, caring, and professional interactions with no complaints, while a larger group reports serious deficiencies that could endanger resident health and safety. For prospective residents and families, the reviews recommend exercising caution. Important follow-ups before placement would include asking about recent health-department inspections and citations, current staffing ratios and turnover, specific infection-control policies, medication administration audits, how complaints are handled, and the status of reported remediation efforts by new management. For families already affected, the volume and nature of the complaints justify escalating concerns to state regulatory authorities if the facility has not addressed them promptly.
In summary, Grand Pavilion at the Plaza shows polarized feedback: pockets of competent, caring staff and leadership are acknowledged, but numerous, recurring reports describe severe and systemic problems with cleanliness, medication and clinical care, staffing, safety, and dining. The frequency and severity of the negative reports — including allegations of neglect, regulatory complaints, and at least one reported death — outweigh the positive comments in terms of risk to residents. Any decision to place a loved one here should be accompanied by in-person inspections focused on hygiene, care practices, staff training, and verification of improvements from management, plus confirmation of regulatory standing and recent inspection outcomes.
