Overall sentiment: The review set for Stonegate Nursing and Rehabilitation is strongly mixed and polarized. Many reviewers praise the facility for outstanding rehabilitation services, individual caregivers, and successful short-term therapy outcomes. At the same time a significant number of reviewers describe serious, recurring problems: short staffing, medication and safety errors, inconsistent hygiene and wound care, poor communication, and administrative unresponsiveness. The result is a facility that can deliver excellent clinical therapy and compassionate attention from individual staff members, but that also demonstrates systemic weaknesses that meaningfully affect patient safety, comfort, and family trust.
Care quality and clinical services: The most consistent strength across these reviews is the therapy program. Physical therapists and occupational therapists are repeatedly described as professional, effective, and instrumental in patient recovery; specific therapists were named and praised for producing measurable mobility improvements. Many reviewers recommend Stonegate for short-term rehab stays due to these positive outcomes. Nursing and aide care is highly variable: multiple accounts describe nurses and CNAs who are kind, attentive, and go above and beyond (including specific named staff and long-tenured caregivers). Conversely, multiple reviews report medication errors, delayed or missing medications, narcotic administration concerns, and inconsistent follow-through on physician orders (including premature discharge decisions and PRN-only medication changes). There are also alarming reports of inadequate wound care in some cases — including an instance described as leading to amputation — while other reviewers praise an outstanding wound care nurse. These contradictions point to uneven clinical oversight and inconsistent execution of care protocols.
Safety, incident reporting, and accountability: Several reviews detail serious safety lapses: falls with missing bed rails, residents found on the floor, alleged ignored fall risks, feces or bodily fluids left in rooms or carpeting, and delayed response during emergencies. Families also reported lost medical records, missing personal items, and theft of clothing. There are reports of residents being moved or discharged without adequate notice or follow-up, and of inadequate communication after adverse events, including after resident deaths. These problems suggest gaps in incident management, documentation, and family communication that raise patient-safety and legal concerns.
Staffing, culture, and management: A central theme is understaffing and high turnover. Numerous reviewers link poor care and slow call responses to reduced staff-to-patient ratios and overworked employees. Some reviewers state that staffing shortages cause skipped showers, delayed meals, and limited social interaction. Staff culture is variable: some staff and administrators are described as professional, caring, and responsive (owners, DON, and certain nurses receive praise), while other reviewers experienced rude or dismissive office staff and managerial unresponsiveness. Several reviewers state that the facility declined in quality following an acquisition, citing cuts in staffing and morale. The mixed reports about management responsiveness — from owners who are “exceptional” to administrators who are “rude” or “dismissive” — indicate uneven leadership at different times or across different units.
Facilities, cleanliness, and physical plant: Reviews show a split perception of the physical plant. Some reviewers mention well-maintained exteriors, renovations, new furniture, and a clean, pleasant environment. Others report areas that are falling apart: temporary air conditioners that don’t work, mildew smells, dusty surfaces, dirty wheelchairs, and filthy rooms. Room configurations are also a concern for many: shared “Jack and Jill” rooms with privacy issues, bathrooms accessible only to one occupant, and a lack of private rooms. These inconsistencies suggest that maintenance and environmental standards vary by unit or have fluctuated over time.
Dining and dietary concerns: Dining receives mixed feedback. Some reviewers praise meal variety and tasty, nutritious food; others report frequent problems with cold meals, missing trays, small portions, delayed delivery, and dietary failures (for example, diabetic residents receiving inappropriate items). There are multiple comments about outsourced meal services and a lack of accountability among dietary staff. Overall, food service appears to be another area with highly variable performance.
Activities and social life: Many reviewers report that activities are a positive aspect of resident life: bingo, karaoke, pet therapy, caroling, and volunteers contribute to engagement. At the same time, some families complained of limited socialization or staff too busy to spend time with residents. The availability and quality of programming therefore appears to depend on staffing levels and unit management.
Patterns and temporal changes: Several reviewers specifically cite a decline in quality after a change in ownership or staffing reductions. There are repeated references to short staffing becoming more pronounced over time, causing deterioration in hygiene, responsiveness, and oversight. Conversely, some improvements are attributed to staffing changes, management attention, and specific staff hires that improved attitudes and care quality.
Notable extremes and red flags: The reviews include extreme positive reports (spotless facility, exceptional therapy and nursing, very high recommendations) and extreme negative allegations (theft, narcotics administered without permission, neglect leading to severe wound outcomes, residents left unattended, and lack of response after deaths). These extremes point to systemic inconsistency: when the right staff are present and leadership is engaged, outcomes are very good; when staffing or oversight lapses, outcomes can be dangerous.
Recommendation and considerations for families: Families considering Stonegate should weigh its strong rehabilitation program and presence of many compassionate, skilled caregivers against recurring reports of staffing shortages, safety incidents, medication and wound-care lapses, privacy issues, and inconsistent administration. It is advisable to ask specific, current questions about staffing ratios for the unit of interest, wound-care protocols, incident reporting and notification policies, private-room availability, and up-to-date references from recent families. Visiting the facility in person, observing shift changes, speaking directly with the therapy team and DON, and getting written clarification about medication and discharge policies can help determine whether the current environment meets a prospective resident’s needs.
Bottom line: Stonegate demonstrates real strengths — particularly in rehabilitation, several outstanding clinical staff, and positive social programming — but also repeated, serious concerns centered on understaffing, safety, medication and wound-care management, and inconsistent administration. The facility can provide excellent, family-like care in many cases, but variability is high and there are documented instances of neglect and harmful outcomes that require careful scrutiny by prospective residents and families.
