During a May 1 inspection, kitchen staff tested the temperature of a meal tray and found chicken stir fry with vegetables measured just 117.3 degrees Fahrenheit. The facility's own service line checklist showed the same dish left the kitchen at 174 degrees — a temperature drop of more than 50 degrees.
The dietary supervisor tasted the chicken and rice during the inspection and told investigators "the food was barely warm." She said residents "would not like to eat the food because it was cold" and blamed the plastic containers for failing to retain heat.
Other items on the test tray showed similar problems. White rice dropped from 176 degrees in the kitchen to 131.2 degrees on delivery. Dinner rolls measured just 86.7 degrees.
Resident 5, who has hypertension and understands conversations, told inspectors the food arrived "semi cold" and "not appetizing to eat, especially when eating in a plastic container." She said the coffee was cold and opening the plastic containers was "very frustrating." When she complained to the dietary supervisor about these issues, "the dietary supervisor did not address it."
The resident said she "did not want to eat in the facility."
Resident 9, a diabetic with hypertension, was more blunt during his May 6 interview. "Food was horrible, cold and it should not be cold," he told inspectors. "I was sick of the plastic food container, and it had continued for a while."
He said residents repeatedly invited the dietary supervisor to meetings to raise concerns about the food, "but he never shows up." The administrator, he added, "never asked about the food here."
The Director of Nursing defended the plastic containers during her May 1 interview, saying the facility switched to disposable containers and utensils "since the elevator was not working." She claimed staff forming lines on stairs to pass trays was an acceptable solution.
"Eating in a disposable plastic container did not affect the residents and it was like ordering food from the outside," she told inspectors. She insisted the plastic containers could "retain heat for it to reach the residents" and said she had not received complaints.
But the dietary supervisor contradicted her four days later. During a May 5 interview, she acknowledged the facility was still using disposable containers and admitted "the residents would not like the food, they would not eat it and complained about it."
She called eating from disposable containers "not presentable" and said the facility should only use them "during emergency situations."
"We don't use disposable at home and this is the resident's home," she told inspectors.
The temperature problems weren't the only food service failures inspectors found.
Resident 7, who has hypertension and requires assistance during meals, received salisbury steak with sliced onions on his tray during a May 5 observation. His physician's orders specifically stated "no onions," and his meal ticket confirmed the restriction.
The Infection Preventionist Nurse who was present during the observation told inspectors Resident 7 "should not receive onion because Resident 7 did not like it and most likely the resident would not eat his food."
The Director of Nursing acknowledged the error when shown the physician's orders. She said serving onions to Resident 7 was problematic because "it would affect their nutrition status" and "if we don't honor it the resident could lose weight and won't eat it."
The facility's own policy requires staff to treat residents "with respect and dignity" and provide "a safe, clean, comfortable, and homelike environment." Another policy mandates offering residents "nourishing, palatable, well balanced food" that meets their "daily nutritional needs, taking into consideration the preferences of each resident."
Inspectors cited the facility for failing to ensure food was "palatable, attractive, and at a safe and appetizing temperature" and for not following dietary orders that meet residents' nutritional needs.
The violations affected 151 of the facility's 158 residents who receive regular, therapeutic, and pureed diets. Inspectors noted the deficient practices placed residents at risk of unplanned weight loss due to poor food intake.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brier Oak On Sunset from 2025-05-06 including all violations, facility responses, and corrective action plans.