Overall impression: The review set shows a deeply polarized and volatile pattern of experiences at Rose City Rehabilitation Center. A substantial number of reviewers report severe, systemic problems: allegations of abuse and physical assault by staff, pervasive neglect of basic personal care needs, serious medical and safety lapses, and unacceptable facility hygiene issues. These accounts are serious — including extreme weight loss, missed or incorrect medications, ignored call bells, lack of assistance after falls, stained and unsanitary bedding, and reports of rodents and bugs. At the same time, a distinct cluster of reviewers describe compassionate, hardworking staff and meaningful improvements under newer management. The result is an inconsistent reputation where some families feel the facility provides caring, family-like treatment, while others report horror-story level mistreatment.
Care quality and safety: Many of the most alarming comments relate directly to care quality and resident safety. Several reviewers allege physical abuse (a CNA striking a resident), failure to provide essential hygiene and feeding, and dramatic weight loss in residents. Repeated themes include call bells being ignored or out of reach, missed morning medications, wrong drugs being given, failure to file incident reports after falls, and refusal or obstruction of needed equipment (for example a reclining lift chair). These reports suggest possible systemic understaffing or poor staff training and oversight: staff are described as overworked or spread too thin, which caregivers and families say translates into residents becoming bedfast and declining physically and cognitively over extended stays.
Staff behavior and culture: Reports about staff behavior are highly mixed but lean negative overall. Numerous reviews accuse staff of rudeness, shouting at patients, and treating residents without compassion. Several reviews specifically name nursing staff and management as unhelpful or dismissive when concerns are raised. Conversely, many other reviewers praise individual aides, nurses, and the ADON for being compassionate, proactive, and resident-centered. Multiple testimonials credit newer leaders and department heads with improving morale and care, describing friendly, welcoming, and cheerful interactions. This split suggests substantial variability across shifts, units, or personnel, with pockets of genuinely committed staff operating within a facility that has at times failed to enforce consistent standards.
Facility, cleanliness and infection control: Cleanliness and environmental safety are recurring issues. Negative reviewers report strong urine/stench odors, stained sheets and blankets with blood or urine, and concerns about infection risk. Others describe rodents, discarded furniture near windows, bugs, and generally unsanitary conditions. In contrast, some reviewers explicitly note that smells have abated, halls are cleaner, and housekeeping has improved under recent management changes. The overall pattern indicates episodes or periods of poor housekeeping and pest control that some families observed had been addressed later by staff changes.
Administration and record-keeping: Administrative and systems failures are frequently mentioned. Specific allegations include management refusing to provide medical or incident records (even after court orders), double billing, opening residents’ mail, and poor front-desk communication (wrong room numbers, inconsistent reception). One reviewer reported an “extra medical procedure” and management’s refusal to share findings. These are serious governance concerns and point to lapses in transparency, accountability, and administrative procedure.
Dining, activities, and social engagement: Multiple reviewers complained about poor dining quality (examples such as bologna sandwiches and bland potato salad were given) and lack of meaningful engagement for residents: some residents were reportedly confined to rooms with few activities or social interactions. Other reviewers praised staff who tried to engage residents and noted efforts to improve the social environment. Overall, social programming and consistent mealtime quality appear uneven across the facility.
Patterns and variability: A dominant theme is inconsistency. Some families reported outstanding, respectful care and recent improvements following leadership changes. Others reported long-term declines for residents during lengthy stays (up to a year), describing neglect and safety problems so severe that they removed loved ones as soon as possible. This suggests the facility may perform differently across shifts, units, or under different management teams, and that quality may be highly dependent on which staff are on duty.
Takeaway: The reviews reveal two distinct narratives: one of serious, systemic failures leading to neglect, safety risks, and poor living conditions; and another of dedicated staff members and leadership efforts aiming to repair past problems and improve resident-centered care. The severity of the negative reports (abuse allegations, missed medications, unsanitary conditions, and administrative opacity) is significant and should be taken seriously. At the same time, multiple families attest to recent positive changes, cleaner conditions, and compassionate staff. For prospective families or advocates, the most striking conclusion is that experiences appear to vary widely — so close monitoring, clear documentation, frequent visits, and direct conversations with management and the clinical leadership would be prudent. If problems are observed, escalate promptly to facility leadership and external oversight authorities because several reviewers reported ineffective internal resolution and alleged that management failed to appropriately disclose or address incidents.
