Overall sentiment in these reviews is highly polarized and inconsistent: many reviewers praise specific aspects of Legacy Miamisburg (especially therapy, some nursing aides, housekeepers, admissions, and the physical plant), while a substantial number of reviews describe serious, potentially dangerous failures in clinical care, safety, and staffing. The result is a facility that can deliver excellent rehabilitation and compassionate attention for some residents, yet simultaneously exhibit neglectful or unsafe practices for others. This split pattern is a dominant theme and suggests variability by shift, unit, or personnel.
Care quality and safety The most consequential pattern in the reviews is unpredictable clinical care. Multiple reviewers report medication errors, delayed or missed medications, and medications changed without appropriate specialty consultation. There are several specific claims of missed wound dressings, failure to follow physician orders (including necessary positioning aids like medically indicated pillows), and inconsistent post-operative or post-procedure care. Several accounts describe malnutrition, dehydration, UTIs, over-sedation, multiple falls, bruising, and injuries; at least one reviewer links alleged staff neglect to hospitalization and death. These are severe allegations that, if accurate, represent major safety and quality-of-care failures. Conversely, other reviewers describe excellent rehab outcomes and recovery progress, which underscores the variability: rehab/therapy teams are frequently singled out as high-performing and effective, but nursing and medication management appear uneven.
Staff performance and behavior Reviews paint a mixed picture of staff. Many nurse aides and therapists receive high praise for being caring, patient, and effective; some nurses and a named Director of Nursing also receive positive mentions. Admissions and some managers are described as helpful and communicative. However, a significant number of reviews cite serious staff-related problems: understaffing, unresponsiveness to call lights, staff distracted by cell phones, staff sleeping at desks, and poor after-hours communication. Several reviewers note that call bells are not monitored and that emergency bells go unanswered. There are also reported instances of unprofessional or rude employees, failure to recognize patients, and aides who violate privacy or hygiene expectations. The contrast between highly praised individuals/teams and accounts of neglect suggests inconsistent staffing levels, training, or culture across shifts.
Facilities, cleanliness, and environment Physically, Legacy Miamisburg receives many positive comments. The building, common areas, and private dining rooms are frequently described as clean, bright, and well-maintained; rooms are noted to be spacious, handicapped-accessible, and equipped with wall-mounted TVs and internet. Several reviewers specifically praise housekeeping. Nonetheless, other reviews report disturbing sanitation issues — dead spiders, bugs, and dirty areas — indicating that cleanliness standards may vary by wing or over time. Halls full of equipment and clutter are also mentioned, contributing to sleep disruption and potential hazards.
Dining and basic resident needs There is substantial negative feedback about food service and basic care tasks. While the dining areas themselves are often well-appointed, reports include inedible food, repeated menus (e.g., repeated ham sandwiches), incorrect meal tickets, confusion about diet requirements, and occasions where patients were not fed upon arrival. Basic supplies and assistance are also inconsistently provided: water left in rooms not refilled, no towels or soap available at times, and assistance with showers sometimes not offered. On the other hand, a few families note that dietician issues were eventually resolved and some residents enjoyed meals.
Management, communication, and administration Management and administration receive mixed reviews but with a notable amount of criticism. Several reviewers describe ownership changes, unstable management, slow responsiveness, and poor communication with families, including unresponsive after-hours phones and long appointment delays. Some staff and family members raise concerns about employee treatment and potential illegal changes to benefits. Positive comments exist for specific administrators and staff (including admissions personnel and a Unit Manager/LPN who helped one family), but overall the pattern points to administrative inconsistency and periods of inadequate oversight. Several reviews explicitly call for investigations or closure of the facility due to safety concerns — a serious reputational and regulatory red flag.
Patterns and recommendations Key patterns to note: (1) rehab and therapy are frequently cited as strengths and may be the facility's best-performing area; (2) nursing and medication management are inconsistent, with repeated reports of missed medications, missed wound care, and safety incidents; (3) staffing shortages and after-hours communication gaps appear systemic and recur across reviews; and (4) facility appearance is generally positive, but cleanliness and sanitation issues have been reported. Because experiences range from “top notch” to “very poor” and include allegations of neglect and death, anyone considering this facility should perform targeted due diligence: visit multiple units and shifts, ask for written policies on staffing, medication administration, wound care, and emergency procedures, verify current management and ownership, review recent state inspection and complaint records, and talk directly with current families about consistency of care on evenings and weekends.
Bottom line Legacy Miamisburg demonstrates clear strengths — particularly in physical therapy, some aides, housekeeping (in many reports), and an attractive physical environment — but there are recurring, serious concerns about nursing reliability, medication safety, sanitation in some areas, and management consistency. The facility appears capable of providing excellent rehab outcomes for some patients, but the frequency and severity of negative reports raise concerns about systemic issues that could jeopardize resident safety. Prospective residents and families should weigh the facility's therapy strengths and pleasant environment against the documented risks, seek current and specific assurances from administration, and consider additional oversight or alternative placements if safety and consistent nursing care cannot be confidently verified.
