Overall sentiment: The reviews of Sapphire at Fernhill are overwhelmingly negative, with a small number of isolated positive comments about staff friendliness or food. Most reviewers describe systemic problems affecting care quality, facility condition, safety, communication, and management transparency. Several reviewers reported serious adverse outcomes (hospitalization, worsening wounds, infection, amputation, and death) that they attribute to neglect, errors, or inadequate treatment while at the facility.
Care quality and clinical concerns: A dominant theme is substandard clinical care. Multiple reviews recount medication errors and missed pain medications, with some patients reportedly left in pain for extended periods and families not notified promptly. Reviewers describe delayed or inadequate wound care, bedsores that worsened under the facility’s watch, and at least one case where infection progressed to a severe outcome (amputation). There are also allegations of missed post-operative follow-up and poor or non-performed rehabilitation/physical therapy. These clinical lapses in basic nursing tasks and therapy contribute to several hospital transfers and at least one death cited in the reviews, prompting state-level investigation in one report.
Safety, allegations of abuse, and serious incidents: Several reviews contain alarming allegations of physical abuse or unexplained injuries — bruises, defensive marks, and a suspected broken nose are specifically mentioned — and families report receiving incomplete information after deaths or serious incidents. Reviewers describe defensive or evasive behavior from administration, perceived dishonesty about events, and lack of transparent communication about investigations or autopsy results. Taken together, these accounts raise significant safety and oversight concerns.
Facility condition and maintenance: The building is repeatedly described as old, cold, and in disrepair. Multiple reviewers report strong urine odors, filthy rooms, thin mattresses, shallow closets, few working electrical outlets, and rooms without private bathrooms. Reports of cold drafts and makeshift window repairs (plastic or Saran Wrap over windows) indicate inadequate climate control and poor upkeep. There are also mentions of roof collapse, persistent construction and trash heaps, and broken doors or accessibility problems, all contributing to a sense that the facility’s physical plant is neglected and disruptive to residents’ lives.
Dining and nutrition: Dining emerges as another major area of dissatisfaction. Numerous reviewers complain of poor-quality food — cold meals, runny or watered-down items, unappetizing choices (cold sausage), and lack of hot or properly prepared entrees. A few reviews, however, contradict this pattern by praising the food as healthy or good; this suggests inconsistent meal quality. There are also concerns that the facility allowed inappropriate food (junk food) for residents with dietary restrictions, such as those with diabetes.
Staff behavior, communication, and management: Reviews present a mixed but mostly negative picture of staff and leadership. While some reviewers explicitly note friendly or caring staff, many more describe staff as rude, defensive, disengaged, or unhelpful. Frequent complaints include poor phone communication, lack of callbacks, failure to notify families about changes in condition or medication errors, and inadequate answers about care plans. Residents and families report call lights going unanswered and staff leaving residents unattended during personal care, which further undermines confidence in day-to-day supervision. Several reviewers express distrust of management, citing perceived dishonesty and inadequate response to serious complaints.
Therapy, activities, and environment: There are repeated complaints about the absence or inadequacy of rehabilitation services and a general lack of activities for residents. Where therapy is expected, some families report it was not scheduled or not performed. The environment is described as depressing or uncomfortable — small rooms, shared long-term roommates, strong smells, and little privacy — which reviewers say contributes to poor quality of life.
Patterns, variability, and final assessment: While a minority of reviews praise staff or food, the preponderance of feedback indicates systemic problems. The most consistent and serious themes are medication and care errors, poor wound management, filthy and poorly maintained facilities, very low dining standards, and poor communication from staff and administration. Several reports of hospitalization, serious complications, and death tied to facility care elevate concerns from poor service to potential harm. Given these patterns, reviewers advise caution: monitor loved ones closely, insist on documented care plans and timely communication, and consider regulatory reporting if clinical neglect or abuse is suspected.
Recommendations based on patterns observed: Prospective residents and families should seek detailed, written information on medication administration systems, wound-care protocols, staffing levels, and emergency notification policies. Visit multiple times (including nights and mealtimes), inspect rooms and common areas for cleanliness and maintenance, ask for recent inspection reports and responses to complaints, and verify therapy schedules. Families of current residents should document incidents, insist on timely escalation for missed medications or wounds, and consider contacting state long-term care ombudsman or licensing authorities if serious lapses or abuse are suspected.
