Overall sentiment in the reviews is highly polarized and inconsistent: many reviewers report compassionate, skilled individual staff members and satisfactory rehabilitation services, while an equally large set of reviews describe serious neglect, unsafe conditions, and management failures. The recurring pattern is variability — some residents and families experienced respectful, attentive care and effective therapies, while others encountered repeated lapses in basic nursing care, facility maintenance, and safety.
Care quality: Reviews indicate a wide range in clinical care. Positive accounts emphasize timely medications, attentive aides and nurses, and effective physical/occupational/speech therapy programs for certain residents. However, numerous negative reports describe neglectful care: failure to change soiled bedding, residents left in feces for hours, weight loss, poor personal hygiene, missed baths, and water or hydration not provided. Several reviewers identified clinical safety failures such as poor aseptic technique for wound care, staff lacking tracheostomy care knowledge, no call light in a room, and a trach cuff left inflated that prevented communication. Medication management is inconsistent — some families said meds were on time while others reported lost medications and missed antibiotic orders.
Staff and management: Reviews portray staff behavior as highly inconsistent. Many single-out aides, nurses, therapists, and even an office manager, DON, or administrator as compassionate and professional, creating a family-like atmosphere for some residents. Conversely, other reviewers report rude, unprofessional, or incompetent leadership (including the DON and administration), with allegations that administration prioritized bed placement/long-term placement over individual patient care. Staffing shortages are a prominent theme; nurses often described as "too busy," leading to omissions in basic care. Some families reported that staff failed to act on safety concerns or threats from other residents. There are also multiple allegations of poor communication from management and failure to provide oversight (e.g., house physician reportedly not visiting patients).
Facilities and safety: Several serious facility-related concerns appear repeatedly. These include an extended air-conditioning outage that required moving patients, a ceiling reportedly falling near a bed, inadequate linens and supplies, general uncleanliness and urine odors, and zero security to manage disruptive residents. These conditions combine with staffing problems to create notable safety risks for some residents. The presence of disruptive residents on antipsychotics and reports that staff did not sufficiently intervene add to safety concerns.
Dining and amenities: Reports about dining are mixed. Some residents praised the food, snacks, and availability of beverages (ice water, tea, coffee), while others described meals as stale, moldy, cardboard-tasting, or missing items. Reviewers also noted that staff smoke breaks and staffing practices sometimes interfered with meal service and medication administration.
Rehabilitation and activities: Rehabilitation services receive both praise and criticism. Several reviewers specifically complimented therapists and the VA rehabilitation floor, reporting positive outcomes and good therapy staff. Other reviews describe delayed or advocated-for rehab services and a lack of rules/handouts or structured programming. Activities are reported positively in some cases (residents taken outside, staff-organized outings), but COVID-related policies were also cited by multiple families as keeping residents isolated in rooms for extended periods, negatively affecting quality of life.
Notable patterns and recommendations based on themes: The dominant pattern is inconsistent care and quality — excellent, attentive care from individual staff is often undermined by systemic problems: understaffing, poor facility maintenance, inconsistent leadership, and lapses in clinical technique. Safety issues (trach care, falling ceiling, lack of call lights, unaddressed disruptive residents) and hygiene/neglect allegations are the most serious recurring concerns. Families considering this facility should be prepared for variability depending on unit, shift, or specific staff on duty. For current residents, reviewers’ actions that mitigated problems included persistent family advocacy, close monitoring of wounds/medications, documenting incidents, and escalating concerns to facility leadership or regulatory bodies when care was unsafe. The reviews suggest that regulatory attention and managerial improvements would be necessary to address the systemic issues described, even though many individual staff members are praised for compassionate care.
