Overall sentiment across reviews is highly mixed but leans negative, with recurring and serious concerns about management, staffing, cleanliness, safety, and consistency of care. Many reviewers describe a facility with pockets of good caregiving—notably the rehab/therapy team and a number of individual aides or nurses who are compassionate and effective—but these positives are frequently overshadowed by systemic problems that affect resident safety, hygiene, and wellbeing.
Care quality and safety: Reviews repeatedly describe inconsistent clinical care. Several accounts praise rehabilitation staff for effective therapy and post-surgical recovery support, but nursing and aide care is highly variable. Reports include neglected call buttons, extended delays in assistance, missed medications, medication coordination failures (including a methadone incident), and failures to supply or manage essential respiratory equipment such as CPAP machines or oxygen. Serious safety incidents are described multiple times: resident falls, choking events, residents being punched, and abusive or violent patients not adequately managed. There are also instances of hospitalization after non-responsiveness and at least one report of a patient death. These patterns suggest unreliable basic monitoring and response systems in multiple shifts.
Staffing and personnel issues: A central and repeated theme is understaffing and high staff turnover. Reviewers report heavy reliance on agency aides, weekend staffing shortages, nurses' stations frequently unattended, and phones not being answered. Staff behavior is described as a spectrum from genuinely caring and compassionate to rude, uncaring, and unprofessional; favoritism and talk-down behavior toward residents are noted. Multiple reviews point to management problems—frequent executive director changes, administrative instability, HR and finance irregularities (including reports of missing funds), and a generally unresponsive or antagonistic administration. There are also alarming allegations of racial harassment and bullying culminating in police involvement in at least one incident.
Facilities, cleanliness, and maintenance: Cleanliness and upkeep are major, recurring issues. Numerous reviewers report dirty rooms, smells, linens not changed, trash left in rooms, and lapses in personal hygiene supports (e.g., prolonged lack of showers). Pest problems including bed bugs and ineffective pest control are explicitly reported. Maintenance and building issues are noted alongside phone system failures and broken or unreliable resident services. Contrastingly, several reviewers do describe the facility as clean and well-maintained—these positive accounts often coincide with mentions of different time periods or after ownership changes, indicating variability over time or between units.
Dining and ancillary services: Food quality is another polarized area. Many reviewers label the food as "horrible," cite kitchen staff problems, and report dietary needs not being honored (e.g., low-sodium diets not followed, lactose intolerance ignored). Others, especially after ownership or management changes, report improvements in food and dining experiences. Auxiliary services have been reduced or disrupted in some accounts: beautician/haircut services discontinued, no on-call aides, and cancellation of rehab services when residents plateau. Some operational basics—like transportation to doctors—are repeatedly mentioned as positives in certain reports.
Memory care and resident mix: The memory care unit is criticized for being poorly matched to resident needs. Multiple accounts indicate the unit houses residents with advanced dementia alongside those with mild cognitive impairment, creating an environment that is emotionally difficult for some families and potentially unsafe or inappropriate for residents who are in earlier stages. Reviewers specifically call out lack of gradation (no two-stage dementia unit) and unsuitable roommate pairings.
Regulatory and reputational issues: Several reviews reference state citations, hundreds of violations in aggregate (one review cites 25 violations specifically), and recommendations from family members that the facility be shut down. There are reports of census limitations, potential closure, and financial/HR problems that exacerbate trust issues with administration. However, some reviews also indicate a turnaround after new management or ownership, with improved survey results, better dining, and a more stable staff noted in those accounts.
Variability and timeline patterns: A notable pattern is strong variability by time, unit, and staff. Multiple reviews describe clear improvements under new leadership (better food, improved head staff, favorable surveys), while many other reviews reflect periods of poor care and unsafe conditions. Positive anecdotes—such as friendly staff, a comforting dining room, well-run activities, and effective rehab—coexist with severe criticisms. This suggests episodic or localized strengths rather than consistent, facility-wide reliability.
Conclusion: The overall picture is of a facility with some real strengths (notably rehab/therapy and individual caring staff) but recurrent systemic failures that have serious implications for resident safety and dignity. The most pressing, repeatedly cited problems are understaffing, poor management and oversight, cleanliness/pest control issues, unreliable communication systems (phones/call buttons), and safety incidents including medication and behavior-management lapses. While a subset of reviews reports meaningful improvements after ownership and leadership changes, the volume and severity of negative reports—state citations, theft of belongings, financial irregularities, bed bugs, and allegations of abuse or harassment—should be weighed heavily by prospective residents and families. Any assessment should consider the timing of individual reviews (whether they pre- or post-management change), request up-to-date regulatory surveys, and seek direct assurances about staffing patterns, incident history, infection/pest control measures, and how memory care placements are managed.
