Overall sentiment is highly polarized: many reviewers report exceptional rehabilitation outcomes, compassionate individualized care, and a warm, home‑like atmosphere, while a substantial number of other reviewers describe serious safety, hygiene, medical, and management failures. The facility receives consistent praise for its therapy teams—physical, occupational, and speech therapy are repeatedly cited as high quality, effective, and instrumental in getting patients home. Multiple reviewers credited particular therapists and therapy heads with prompt, focused programs (real‑life simulations, consistent one‑on‑one work) that produced measurable recovery. When rehab and therapy were working well, families frequently described successful discharges and sustained improvement after leaving the facility.
Caregiving staff quality is the most variable theme. A large portion of reviews praise specific nurses, CNAs, aides and administrators by name for compassionate, attentive care, dignity-preserving practices, and strong communication. These reviewers report that staff became like family, that maintenance and housekeeping were responsive, and that activities and amenities enriched residents' stays. Conversely, another substantial subset of reviewers report rude, inattentive or abusive behavior—especially on night and weekend shifts—with reports of yelling nurses, aides who ignored call lights, slow response times (30 minutes to multiple hours), and basic needs not being met. This inconsistency suggests meaningful variation by shift, team, and individual staff member; several reviews explicitly link poor experiences to understaffing and staff being overworked.
Clinical safety and medication management are frequent and serious concerns. Numerous reviewers reported medication errors (missed doses, incorrect timing, double dosing, and medications crushed when they should not have been). Several accounts describe delayed or absent wound care, open wounds that became infected requiring further surgery, catheter or IV‑related infections, bedsores, and at least one death where families alleged neglect. There are also reports of near‑fatal incidents (BIPAP mismanagement, delayed EMS response) and claims of exposed COVID cases and poor infection-control practices. These safety and clinical issues are among the most consequential negative patterns and were often paired with allegations that administration was unresponsive when concerns were raised.
Dining and nutrition receive mixed marks but lean negative in many reports. While some reviewers said food was good, diverse, and helpful in encouraging eating, many others described inedible or cold meals, dietary restrictions not being honored (wrong food served for restricted diets), missing condiments or straws, meals not delivered, and repetitive menus. Several families reported that meal problems persisted over long stays (e.g., small holiday meals, lack of dinner service initially). Nutrition‑related problems were sometimes linked to declines in patient health or hydration concerns.
Facility cleanliness and equipment maintenance are inconsistently reported. Many reviewers praised the building's appearance, clean common spaces, and well‑kept grounds. Others reported alarming hygiene lapses—bugs in lights, urine smells, standing water in showers, dirty Nourishment Rooms, infrequent linen changes, broken/unsafe equipment (busted wheelchairs, broken beds, missing walker or safety aids), and missing or non-functioning call lights. These mixed observations indicate that some units, shifts, or rooms are well maintained while others fall short; such inconsistency increases risk and undermines trust.
Communication, administration, and discharge/transfer logistics also surface repeatedly. Positive reviews highlight helpful admissions, coordinated discharge planning, supportive social workers, and clear instructions for home care. Negative reports describe unhelpful administration, ignored complaints, rushed or incorrect discharges, lost documentation or testing (lost EKG), billing or transportation disputes, refusal to consider alternative transfer options, and opaque Medicare/billing issues. Transportation and ambulance arrangements were a sticking point for many families—difficulties booking transport, unexpected costs, and disputes about transfers to other facilities or the hospital were commonly reported.
Activities and amenities are frequently praised by satisfied residents: live music, birthday parties, church services, trivia, arts & crafts, pet therapy, and spa services were cited as meaningful quality‑of‑life elements. Where activities and attentive staff were present, reviewers report residents feeling less isolated and more engaged. Conversely, when staffing or management problems interfered, some residents felt lonely, ignored, or unsafe.
In summary, CareOne at Madison Avenue appears to deliver high‑quality rehabilitation and outstanding care in many cases—especially where therapy teams, certain nurses, and administrators are engaged and adequately staffed. However, recurring and serious concerns around understaffing, medication and wound‑care errors, poor night/weekend coverage, inconsistent cleanliness, food service failures, and weak complaint handling create substantial risk for some residents. The reviews suggest a facility with real strengths (notably rehab and many dedicated staff members) but also systemic vulnerabilities that lead to widely divergent patient experiences. Prospective residents and families should weigh the facility’s strong therapy reputation and the names of praised staff against reported safety and staffing inconsistencies; if choosing this facility, insist on clear staffing/therapy plans, documented medication and wound‑care protocols, frequent communication with administration, and direct verification of dietary and equipment needs during the stay.
