LOS ANGELES, CA - State inspectors documented serious maintenance deficiencies at Beverly West Healthcare during a January 27, 2025 complaint investigation, including an actively leaking ceiling that dripped water onto a resident's bed for two days and malfunctioning thermostats affecting multiple resident rooms.
Persistent Water Intrusion Creates Hazardous Conditions
Inspectors found two residents sharing a room where ceiling damage from repeated water leaks had created an unsafe environment. The ceiling above one resident's bed showed visible deterioration including a dent, cracks, and water staining. During the inspection, water was actively dripping from the ceiling onto the bed and pooling on the floor below.
The facility's Maintenance Director acknowledged the roof had been repaired multiple times without success, stating the ceiling "would constantly leak with water whenever it rains." The weight of accumulated water had caused the ceiling to sag and crack, creating structural damage visible to inspectors.
Water infiltration in healthcare settings creates multiple serious risks beyond the immediate slip-and-fall hazard. Persistent moisture promotes mold growth, which can trigger respiratory problems, allergic reactions, and asthma attacks in vulnerable populations. For residents with chronic obstructive pulmonary disease or other respiratory conditions, mold exposure can cause severe complications requiring hospitalization. Additionally, water damage to ceiling materials can compromise structural integrity, potentially leading to ceiling collapse.
Staff reported the leaking began two days before the inspection, yet the residents remained in the compromised room. The facility's response was limited to moving the beds away from the direct leak area and placing buckets to catch dripping water. Neither resident was relocated to a safe room despite the ongoing hazard.
One resident affected by the ceiling leak had diagnoses including atrial fibrillation and hypertensive heart disease, while requiring a wheelchair for mobility. The other resident was cognitively intact and independent with daily activities. The Registered Nurse on duty acknowledged "the water leaks put residents at risk of safety hazard and placed them at risk of falls due to wet area and floors."
Temperature Control System Failures
Inspectors also identified malfunctioning thermostats in multiple areas of the facility, including at least two resident rooms and the Director of Nursing's office. The Maintenance Director confirmed the thermostats could not be adjusted despite attempts to regulate temperature for resident comfort, indicating "there may be electrical or mechanical failure."
Proper temperature regulation is medically critical in skilled nursing facilities. Older adults have reduced ability to regulate body temperature due to age-related changes in metabolism and circulation. Exposure to cold temperatures can lead to hypothermia, which occurs more quickly and at higher temperatures in elderly individuals than in younger adults. Cold stress can also elevate blood pressure, increasing the risk of heart attack and stroke in residents with cardiovascular disease.
Conversely, excessive heat can cause dehydration, heat exhaustion, and heat stroke. Many common medications prescribed to nursing home residents, including diuretics and beta-blockers, impair the body's ability to regulate temperature and increase vulnerability to both heat and cold extremes.
The Director of Nursing acknowledged the thermostats were not working properly and stated that residents "may be compromised" by the inability to maintain appropriate room temperatures. According to staff interviews, multiple residents occupied the rooms where climate control had failed.
Failure to Follow Facility Maintenance Standards
The facility's own maintenance policy, reviewed January 25, 2024, establishes clear expectations that the maintenance department must maintain buildings and equipment "in a safe and operable manner at all times." The policy specifically requires maintaining buildings "in good repair and free from hazards" and keeping heating and cooling systems "in good working order."
Federal regulations require nursing homes to provide a safe, functional environment that accommodates resident needs and maintains their dignity and quality of life. When facilities fail to address known hazards promptly, they violate residents' right to safe accommodation and potentially expose them to preventable injuries and health complications.
Industry best practices call for immediate resident relocation when environmental hazards like water leaks cannot be resolved within hours. Repair attempts should not occur while residents remain exposed to ongoing risks. Similarly, climate control failures should trigger emergency protocols to protect resident safety until systems can be restored to proper function.
Additional Issues Identified
Beyond the major maintenance failures, the inspection revealed concerning facility practices regarding hazard response. Staff demonstrated inadequate emergency procedures by allowing residents to remain in rooms with active water leaks for multiple days. The facility also failed to implement temporary solutions such as portable heating or cooling units for areas with thermostat failures.
The maintenance department's inability to successfully repair the recurring roof leak despite multiple attempts suggests either inadequate resources, insufficient expertise, or systemic neglect of building infrastructure. The visible structural damage to the ceiling indicates the problem had existed for an extended period before the complaint inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beverly West Healthcare from 2025-01-27 including all violations, facility responses, and corrective action plans.
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