LOS ANGELES, CA - A Los Angeles nursing home faced significant operational challenges when a prolonged elevator malfunction led to cold food service and multiple infection control violations, according to a state inspection report from May 2025.
Extended Elevator Outage Disrupts Food Service Operations
Brier Oak on Sunset experienced a months-long elevator malfunction that severely impacted the facility's ability to deliver hot meals to residents. The elevator repair was delayed for several months due to payment disputes between the facility and the elevator service company, Elevator Support Services Inc.
According to maintenance records reviewed during the inspection, invoices dating from November 2024 through February 2025 remained unpaid for months. The facility owed $1,382.96 in outstanding elevator maintenance fees, with some invoices not paid until April 4, 2025 - nearly five months after the original November 2024 service date.
The Maintenance Director explained that repair delays occurred because "the elevator company asked the facility to pay for March, April and May payments before they would come out." The Administrator confirmed the payment issues, stating she had used her personal credit card to pay the company but repairs were still not completed.
Cold Food Service Compromises Resident Nutrition
With the elevator out of service, staff were forced to use disposable plastic containers and form human chains on the stairways to deliver meals to upper floors. This makeshift system resulted in consistently cold food reaching residents.
During the inspection, Kitchen Aid staff and the Dietary Supervisor tested the Chicken Stir Fry with Vegetables being served to residents. The Kitchen Aid reported the food was "barely warm," while the Dietary Supervisor acknowledged that plastic containers could not retain heat effectively. The Dietary Supervisor admitted "the residents would not like to eat the food because it was cold."
Residents confirmed these problems during interviews. One resident stated the food was "semi cold when it arrived, not appetizing to eat, especially when eating in a plastic container," and complained that "the coffee was cold" and "it was very frustrating to open the plastic container." Another resident described the food as "horrible" and "cold," expressing frustration about being "sick of the plastic food container."
The inadequate food temperature poses serious health risks for nursing home residents, who may already have compromised immune systems and nutritional challenges. Hot food service is essential for preventing bacterial growth and ensuring proper nutrition absorption, particularly critical for residents with diabetes and other chronic conditions.
Multiple Infection Control Failures Identified
Inspectors documented several concerning infection control violations that could potentially spread diseases among vulnerable residents. Staff were observed improperly storing personal items in clean linen carts, failing to use required protective equipment, and mishandling medical supplies.
A Certified Nursing Assistant was caught storing his personal drinking cup inside a clean linen cart and drinking water in hallways. When questioned, the CNA acknowledged he "was not supposed to store his personal cup in the clean linen cart due to contamination," yet continued the practice after being observed.
More seriously, staff failed to follow Enhanced Barrier Precautions for a resident requiring wound care. A CNA was observed without a required gown while dressing a resident and changing bed sheets. The staff member admitted she should have been wearing protective equipment "because Resident 10 was on EBP due to Resident 10's wound to protect myself and other residents."
Additional violations included staff returning potentially contaminated linens from resident rooms to clean linen supplies, improper use of protective equipment in isolation rooms, and failure to properly date medical equipment like nasal cannulas and humidifiers.
Medical Equipment Safety Compromises Patient Care
Respiratory equipment was found undated and improperly maintained, creating potential infection risks for residents requiring oxygen therapy. A nasal cannula was discovered on the floor without proper dating labels, while a humidifier lacked required date markings.
The facility's own policies require that nasal cannulas and humidifiers be labeled with setup dates to track when equipment should be changed. Undated equipment prevents staff from knowing when devices were last cleaned or replaced, potentially allowing harmful bacteria to accumulate in equipment directly connected to residents' airways.
The Infection Preventionist explained that bacteria buildup in unchanged humidifiers could compromise oxygen delivery to residents and potentially cause respiratory infections in vulnerable patients.
Industry Standards Require Systematic Infection Prevention
Nursing homes must maintain comprehensive infection prevention programs that include proper hand hygiene, protective equipment protocols, and equipment sterilization procedures. The facility's own policies outlined appropriate procedures for linen handling, personal protective equipment use, and medical device maintenance.
Enhanced Barrier Precautions are specifically designed to prevent transmission of multidrug-resistant organisms during high-contact resident care activities. These protocols require staff to wear gowns and gloves when providing wound care or handling residents with certain medical conditions.
The violations represent systemic failures in staff training and supervision, particularly concerning given that nursing home residents face heightened infection risks due to age, chronic conditions, and close living quarters. Proper infection control is essential for preventing outbreaks of serious illnesses that can be life-threatening for elderly residents with compromised immune systems.
The inspection revealed that while the facility had appropriate written policies, staff consistently failed to follow established protocols, indicating inadequate oversight and training programs.
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.
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