Overall sentiment across the reviews is mixed-to-very-polarized with clear patterns of strong frontline caregiving juxtaposed against systemic operational, facility, and administrative problems. The most frequent and consistent positive theme is the quality of bedside care: many reviewers describe nurses, CNAs, and therapists as compassionate, attentive, and skilled. Physical and occupational therapy are repeatedly credited with producing tangible improvements (for example, helping residents progress from walker to cane). Several reviewers praised staff teamwork and noted staff going "above and beyond," creating a family-like atmosphere. Where renovations have occurred—new flooring, refreshed common areas, pleasant grounds and a nice lobby—reviewers report a noticeable improvement and a positive resident experience.
However, those positive reports are often undermined by recurring complaints about understaffing and operational deficiencies. Multiple accounts describe chronic staffing shortages (notably a severely understaffed night shift with one nurse and two aides caring for 27 residents) and requested but unfilled positions across housekeeping, laundry, kitchen, and STNA roles. Those shortages are linked in reviews to poor care outcomes: numerous falls (one reviewer cited seven falls over two months) and delayed notifications to families (some reports of fall notification delayed over 12 hours). Staffing gaps also coincide with reports of refusals of needed treatments, distracted staff (breaks and smoking), and general neglect when the unit is short-handed.
Facility condition and maintenance emerge as another major theme with a split in perception. Several reviewers describe areas as modern, well maintained, and attractive, with private rooms and a secure dementia outdoor area. Conversely, others report an aging building with serious infrastructure problems: plumbing leaks, lack of hot water, poor ventilation, water damage, potholes in the parking lot, and an overall "2-star building condition" label. These physical problems are raised not only as aesthetics concerns but as contributors to hygiene and safety issues—urine odors, dirty conditions, and concerns that cleaning and laundry services are insufficient because of staffing shortages.
Dining and kitchen operations are a frequent pain point. While some reviewers praise a healthy, well-planned menu and activities like fresh popcorn and themed meals, there are substantial complaints about food quality and kitchen staffing. Reviewers mention that the facility lacks essential kitchen personnel (dishwashers, servers, cooks, prep cooks, and a kitchen manager) and that these shortages have resulted in inedible meals or forced pureed diets when family members felt regular foods were appropriate. One specific unit (Freedom Court) was reported to need its own kitchen. These operational failings feed directly into nutritional and resident satisfaction concerns.
Administrative and communication issues are strongly represented in the reviews. Families report inconsistent or poor communication, long phone-hold times, and defensive responses from administrators. Several reviews describe billing and financial problems—claims of non-itemized or overpriced bills, bills being sent to family members rather than billed correctly to Medicare or insurance, and allegations of money being taken or improper billing practices. One reviewer made serious accusations about a social worker (rude, deceitful, confrontational, making false claims about doctors and Medicare). There are also mentions of privacy breaches and delays in paperwork (POA) and discharges, which compound family frustration.
Safety and security concerns appear repeatedly: mixing psychiatric and dementia residents without adequate differentiation provoked alarm among some families, and there are reports suggesting belongings are not always safe—raising theft risk concerns. These reports, alongside documented fall incidents and understaffing, paint a pattern in which some families perceive the environment as unsafe or poorly managed.
On management and reputation, the reviews show a clear temporal divide. Several reviewers praise a new management team and new Director of Nursing, crediting them with visible improvements, better programming, increased staff morale, and an optimistic future. Multiple comments say the facility is "turning around," with new programs, themed days, and improved cleanliness. At the same time, a strong negative undercurrent persists among other reviewers who describe the facility as a "dump," "worst facility," or "avoid"—often citing poor past experiences or unresolved systemic issues. This split suggests recent leadership changes may be improving some areas, but significant legacy problems remain noticeable to many families.
Therapy, activities, and resident engagement are definite strengths when present: therapy staff are frequently called out as helpful and effective, and activity calendars, outings, and engagement (singing, arts & crafts, bingo) are appreciated by residents and families. The dementia unit's fenced outdoor area and weekly doctor visits are noted as positives in clinical oversight and resident quality of life.
In summary, Stillwater Skilled Nursing and Rehabilitation appears to deliver high-quality hands-on care from many individual staff members—nurses, CNAs, and therapists—who are compassionate and effective. Yet systemic shortcomings in staffing levels, infrastructure maintenance, kitchen operations, administration, billing practices, and security undermine the overall consistency of care and family trust. There are signs of positive change under new management, but the facility still shows significant variability: some units and time periods offer excellent, well-run care, while others suffer from understaffing, safety incidents, poor hygiene, and administrative lapses. Prospective residents and families should weigh the strong reports of compassionate clinical staff and successful therapy against persistent operational risks (falls, delayed communication, billing and security concerns) and ask specific questions about current staffing ratios, kitchen and laundry capabilities, recent facility repairs, infection control measures, incident notification policies, and current management initiatives before committing. Regular monitoring and clear, enforceable remedies in the problem areas noted above would be necessary to align the positive caregiver reports with consistent, safe, and well-managed facility operations.
