Overall sentiment across these reviews is highly polarized but leans toward serious concerns about safety, care consistency, and management, alongside repeated but narrower praise for frontline caregivers and certain programs. Many reviewers report excellent experiences with specific therapists, nurses, CNAs, and activity staff; these positive notes often reference individual employees by name (for example, therapy staff, Sandra the director of nursing, admissions/front desk personnel like Corrinne, activities director Dolores, and caregivers such as Miata). These positive comments emphasize compassionate bedside care, effective wound care, good interpersonal interactions, social programming, a small/home-like environment, and some well-run dining or event experiences.
However, the negative themes are numerous, frequent, and serious. The most alarming and repeated issues include medication errors (including ignored allergies and missed diuretics), failure to reposition residents leading to bedsores, unsanitary handling and hygiene (dirty bathrooms, stained linens, improper cleaning), and delayed or inadequate responses to acute medical needs (delayed hospital transfers after falls, slow doctor response, UTIs and sepsis hospitalizations). Several reviews allege neglect that led to major harm — falls with fractured hips, prolonged unresponsiveness, and deaths reported without family or in-person hospice present. These reports indicate potential systemic failures in basic nursing care and clinical oversight.
Staffing and management are central patterns in the complaints. Multiple reviewers describe chronic understaffing, high turnover, and frequent use of temporary or inexperienced nurses; some shifts were described as having dangerously low staff-to-resident ratios. Families report a culture where management is financially oriented, blames staff for failures, and removes valued employees rather than addressing root causes. Conversely, many frontline staff are personally praised as caring and competent; this contrast suggests variability between individual caregiver performance and institutional leadership or systems. Several reviews explicitly name management or administrators as unresponsive or dishonest regarding billing and complaints.
Communication and family experience are another major concern. Families report that complaints are ignored, voicemails are not returned, and there are privacy concerns (HIPAA/privacy violations). Phone access is limited — reports of no facility telephones, little help with cell phones, and even suspected phone theft — which exacerbates family anxiety. Some families also report mishandling of power-of-attorney and financial affairs, unpaid invoices with poor explanations, lost personal items including wedding photos and clothes, and clothing returned mixed with others. These administrative failings contribute to the perception of poor transparency and accountability.
Facility, cleanliness, and environment feedback is mixed. Several reviewers appreciate the small size, woodsy setting, nearby lake, outdoor areas, and community activities (holiday parties, music, trips, beauty parlor). At the same time, many describe unsanitary conditions: soiled sheets, stained towels, filthy bathrooms, brown residues, and reports that cleaning practices are inadequate or even inappropriate (e.g., improper cleaning products). Temperature control is inconsistent; parts of the building are described as hot with inadequate AC. The contrast suggests some units or wings may be maintained better than others, producing widely divergent experiences.
Dining and activities receive mixed reports. Some families commend good food, helpful dining staff, and well-run activities that engage residents. Others report poor meal handling (trays left cold), lack of appropriate texture-modified diets for dysphagia (no puréed or nectar-thickened options), and overall inconsistencies in meal service. Activities staff and certain social workers are repeatedly commended for creating a supportive atmosphere and meaningful programming.
Safety-related allegations are prominent and diverse: delayed medication administration (including pain meds), omissions in critical medicines, residents left on toilets or floors for extended periods, suspected theft, and inadequate infection control leading to pinkeye outbreaks and urinary sepsis. Several reviews mention regulatory escalation — calls to Elder Affairs and the Department of Health — and explicit recommendations that the facility should be shut down from some reviewers. These indicate that some families perceived the problems as beyond isolated incidents and as systemic risks requiring external intervention.
In sum, the reviews paint a complex picture: the facility appears to have strong, compassionate individuals and programs that can provide excellent care for some residents, but there are numerous, serious, and repeated systemic problems in clinical care, staffing, cleanliness, administration, and communication. The result is high variability in resident outcomes and family satisfaction. For prospective residents or families: ask specific, concrete questions during tours and admissions about staffing ratios, management turnover, medication safety protocols, infection control practices, hospice availability, contact procedures, loss-and-replacement policies for belongings, how complaints are handled, and recent surveys or inspection reports. If already involved with the facility and facing concerns, document issues in writing, escalate to named supervisors, and consider contacting local ombudsman or regulatory bodies if problems persist or involve safety risks.
