Overall sentiment is highly mixed, with a clear split between reviewers who experienced attentive, compassionate, and competent hands-on care and reviewers who report serious lapses in safety, infection control, and basic nursing care. Positive comments emphasize direct-care staff who show dedication, personal attention, and responsiveness, a small building environment that fosters rapport, onsite nursing and therapy resources, and occasional strong leadership or new-staff improvements. Negative comments range from administrative and communication failures to very serious clinical failures, including untreated infections, wound neglect, and medication mishaps. Reviews suggest a facility that can provide good care in some circumstances but also has recurring, significant systemic problems that have led to harm for some residents.
Care quality and clinical concerns: Multiple reviews praise individual caregivers and instances of good clinical care, and some families explicitly say clinical needs were met and residents were comfortable. However, the negative reports are severe and specific: residents reportedly left in soiled diapers for hours, Foley catheters alleged to have gone unchanged for 30 days, UTIs not properly treated, wounds unattended, and at least one reviewer links care failures to progression to sepsis, blood clots, and pneumonia. Medication issues are also noted on both ends of the spectrum — some reviewers praise prompt resolution of prescriptions while others allege unnecessary medications were administered or that pain medication was withheld. These clinical lapses represent the most serious and recurring theme and point to potential deficiencies in infection control, wound care protocols, medication administration, and monitoring.
Staffing, culture, and communication: Many reviews highlight compassionate CNAs and a few named staff who provided memorable, positive care and communication. Conversely, there are multiple allegations of understaffing, rude or inattentive front desk personnel (including a named individual), nurses gossiping, and staff who belittled residents. Several reviewers report an unresponsive main line or room phones that do not ring, making family communication difficult. Admissions staff and social work services are repeatedly described as inattentive or unavailable, and there are claims the social worker did not advocate effectively. Transport or scheduling failures (missed doctor appointments/transport) were also reported. This pattern suggests inconsistent staffing and variable staff training or culture depending on shift or management.
Facilities, amenities, and environment: Positive comments note a smaller facility that can feel personal and welcoming, and some reviewers were invited to tour and liked what they saw. But the facility also receives repeated criticism for maintenance and environmental issues: reports of no TV in rooms, no nameplates on doors, two-day AC outages, a broken vent, foul odors, dirty floors, and a dim or dungeon-like atmosphere. These physical environment problems compound clinical and staffing issues and affect residents' comfort and dignity.
Management, leadership, and systemic issues: A consistent theme is management instability and perceived lack of investment by ownership. Reviewers mention frequent interim managers, an administrator in place for only two weeks, and an impression that owners have not adequately upgraded or supported the facility. Some reviewers, however, praise new leadership and note improved collaboration and dedication among recent hires. This split suggests the facility may be in transition; while some improvements are being made, many reviewers feel systemic problems remain unresolved. Allegations of sabotage of a patient transfer and theft of personal items are particularly alarming and, if accurate, indicate a need for formal investigation and stronger oversight.
Dining, activities, and ancillary services: Dining complaints appear in the reviews mainly as safety issues — for example, food served despite known allergies — rather than general dislikes of menu or quality. There is limited information about activities programming in the summaries provided; however, the presence of onsite therapy and positive hospice setup comments indicate some breadth of services. Admissions, settling-in assistance, and individualized hospice coordination were praised by several reviewers, suggesting strengths in transitions for some residents.
Notable patterns and takeaways: The reviews portray a facility with highly variable performance: some residents and families experience respectful, capable, and attentive care, while others report neglect, unsafe practices, and poor communication. The most consequential patterns are lapses in basic nursing care (hygiene, catheter management, wound care), infection management, medication administration gaps, and communication/phone system failures. Management instability and apparent underinvestment in the physical plant and staffing appear to underlie many of these problems. Positive reports cluster around individual staff members and recent leadership efforts, indicating that improvements are possible but not yet consistent.
Recommendations implied by the reviews: The facility should prioritize immediate audits and corrective action in infection control, wound care, catheter management, and medication safety. Strengthening front-desk responsiveness and phone systems, addressing staffing shortages and training to improve resident dignity and communication, resolving physical plant deficiencies (AC, ventilation, cleanliness, room amenities), and stabilizing leadership would address the most frequent and serious complaints. For families deciding on this facility, the reviews suggest asking specific, direct questions about clinical protocols for wound and catheter care, staffing ratios and turnover, phone/communication reliability, incident reporting, and the facility's response to past adverse events. A personal tour and meeting with clinical leadership, as some reviewers recommended, may help gauge whether recent leadership changes have produced consistent improvements.
