Overall sentiment: Reviews of Brier Oak on Sunset are highly polarized but skew strongly negative when aggregated. A meaningful minority of families describe caring, competent nurses, helpful CNAs, effective therapy outcomes, and useful administrative assistance. However, a larger and recurring set of reviews describe systemic problems with clinical care, staffing, communication, cleanliness, and management practices. Multiple reviewers named specific staff members both positively and negatively, which underscores the inconsistency of the experience: some individual caregivers are praised as exceptional, while others are portrayed as unresponsive, rude, or abusive.
Care quality and clinical safety: Many reviewers raise serious concerns about basic clinical care. Recurrent complaints include long delays in nurse response and medication administration, failures to transfer or reconcile medications after hospital discharge, inappropriate prescribing without family notification, and alleged withholding or manipulation of therapy services to maximize insurance billing. There are multiple reports of wounds, pressure ulcers/bed sores, untreated UTIs, worsening seizures, and other deteriorations that families attributed to neglect. A small but highly concerning number of reviews allege that neglect contributed to hospitalization or death. Conversely, other families reported effective nursing and rehabilitation that allowed successful discharge home; this contrast highlights inconsistent standards of care across stays and shifts.
Therapy and rehab: Rehabilitation services are a prominent area of complaint and praise. Several reviewers strongly allege fraudulent therapy practices—therapists billing long sessions but providing only minutes of active work, staff clocking in from home, and therapists covering multiple buildings without delivering real therapy. These reports are balanced by accounts of successful speech and physical therapy that led to improved swallow function and safe discharge. Overall, the pattern suggests variability in therapy quality and potential billing or documentation concerns that families felt were inappropriate.
Staffing, conduct, and communication: Communication and responsiveness are among the most frequently cited problems. Families report unreachable administrators, hung-up calls, single facility phones with poor access, and social workers or directors who do not return calls. At the same time, certain staff members (Antonio, Romina, and a few named nurses/CNAs) receive strong praise for responsiveness and going above and beyond. There are repeated allegations of unprofessional behavior—staff working while COVID-positive, rude or angry nurses, discriminatory remarks, confiscation of phones, and HIPAA concerns. Several reviews describe management as inaccessible or manipulative (for example, timing discharges to avoid scrutiny and pressuring families). These themes point to inconsistent leadership oversight and poor internal communication protocols.
Facility, cleanliness, and environment: Reports about facility condition vary widely. Some families describe clean, comfortable rooms and a well-kept environment; others report serious cleanliness and housekeeping failures—dead roaches, insects in rooms, urine on restroom floors, sewer-like smells, and run-down areas not matching website photos. Shared rooms, crowded spaces near nurses’ stations, loud roommates, and lack of restful sleeping environments are frequent complaints. There are also multiple reports of logistical and safety failings: broken beds and call buttons, electrical issues, lack of seating in outdoor areas, and inconsistent availability of basic supplies and meal staples.
Dining and basic supplies: Food receives mixed feedback. Several reviewers praise the meals and describe good food, while others report shortages of basic staples (bread, milk), poor meal planning, and being told to bring meals. This inconsistency aligns with broader staffing and supply issues mentioned by families.
Safety incidents and administration: Safety is a repeated area of concern: reports of residents left in soiled diapers for hours, roommate assaults, residents escaping, and inadequate supervision are troubling. Families frequently call for formal investigation and regulatory attention, citing alleged negligence, poor medication management, and pressure to return residents to the facility after incidents. Several reviewers explicitly urge prospective families to research thoroughly before admission and some asked that the facility be investigated or shut down.
Patterns and recommendations: The dominant pattern is inconsistency—some residents receive attentive, even outstanding care, while others experience neglectful or unsafe conditions. Recurring themes that indicate systemic issues include poor communication and administrative responsiveness, staffing shortages or poor staff accountability, variable clinical practices (particularly around medications and therapy), and cleanliness/safety problems. Named staff are repeatedly referenced on both sides of the ledger, suggesting that outcomes hinge heavily on which individuals are on duty.
For prospective families or regulators: Reviewers recommend exercising caution. Verify staffing levels, ask specifically about medication reconciliation and wound care protocols, request examples of therapy schedules and documentation, inquire about infection control practices, and seek references from recent families. If considering admission, ask to meet the nursing leadership, clarify how grievances are handled, and document any promised services in writing. For authorities, the volume and severity of some complaints (neglect allegations, infection control lapses, billing concerns, and claims of deaths or hospitalizations tied to substandard care) warrant closer review.
In summary, Brier Oak on Sunset elicits strong and mixed reactions. There are genuine strengths—compassionate caregivers, some effective therapy, and administrative helpers—but the frequency and severity of negative reports about medical neglect, communication failures, cleanliness, safety incidents, and inconsistent leadership suggest systemic problems that families should carefully evaluate before admission and that regulatory bodies may want to investigate further.
