Absence of Secured Handrails in Facility Corridors
Summary
The facility failed to ensure that the corridors in Unit A and Unit B had firmly secured handrails, as required by the California Code of Regulations. This deficiency was identified through observations, interviews, and record reviews. During an observation, a resident with severely impaired cognition and difficulty walking was seen using a walker in the Unit A corridor, which lacked secured handrails. The resident confirmed the absence of handrails and expressed that having them would enhance safety by providing support for balance. Further observations revealed that two residents were seen navigating the Unit B corridor, which also lacked secured handrails. The Maintenance Supervisor confirmed that the handrails had been removed over three weeks prior for painting and repairs, with no clear timeline for reinstallation. The Director of Nursing (DON) acknowledged that the handrails had been absent for over a month and admitted to not having a specific date for their return. Additionally, the facility did not have a policy or procedure in place regarding handrails. The absence of handrails in the facility's corridors posed a potential risk of increased falls and injuries for residents using these areas. The DON, who started working at the facility after the handrails were removed, agreed that the lack of handrails heightened the risk of falls and injuries. The facility's failure to comply with the regulation requiring firmly secured handrails in corridors was evident, as confirmed by the observations and interviews conducted during the survey.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors identified that corridor handrails were not firmly secured in two resident halls, contrary to the facility’s policy for a safe and homelike environment. During observations, a handrail on the left side of one hall and a handrail on the right side of another hall near the therapy gym were found to be loose to the touch, indicating that the corridors were not maintained with securely affixed handrails on both sides as required.
The facility failed to maintain firmly secured handrails on two of four floors, despite a maintenance policy and a high-priority work order noting needed repairs. Surveyors observed long sections of hallway handrails on the second floor detached from the wall and additional unsecured and missing handrails on the third floor. A CMA and the Resident Council President reported the handrails had been unrepaired for several months and noted that some residents rely on them for safety. The Maintenance Director and NHA both acknowledged awareness of the problem, with the NHA citing delays in obtaining materials as a reason repairs had not been completed.
Facility staff did not maintain corridor handrails in safe condition. During an environmental walkthrough, surveyors observed that some handrails on the 1-South unit corridors were not firmly secured to the wall, and a handrail near one room was missing an end cap. These conditions were acknowledged by the Maintenance Director.
Surveyors found that corridor handrails on two units were loose, shifting several inches, and in some areas pulling away from the wall with visible protruding screws and wall damage. The Maintenance Director confirmed that residents rely on these handrails for balance, safety, and wheelchair propulsion and acknowledged that only one unit’s handrails had been checked after problems were identified. Review of the facility’s preventative maintenance policy showed that routine inspection of handrails was not included.
Surveyors identified multiple unsecured and loose handrails in 3rd-floor hallways, including those near a bathroom and outside several rooms, which could be displaced several inches and in one case had a screw protruding from the bracket. An LPN twice observed and confirmed the looseness of the handrails and acknowledged they are used for safety and to assist residents with gait abnormalities, while the Maintenance Director confirmed the expectation that handrails in common areas be secured and promptly repaired. Despite these acknowledgments and a written preventative maintenance policy requiring inspection of all handrails for loosened fasteners and immediate repair, the same handrails remained loose on subsequent observations.
Surveyors found that multiple hallways and areas lacked required handrails or had handrails that were loose, broken, or missing. Observations included missing handrails near dining rooms, nurses' stations, and restrooms, as well as handrails pulled away from the wall. Interviews with the Maintenance Director and Administrator confirmed awareness of the issue and ongoing replacement efforts, but also revealed gaps in knowledge regarding handrail placement requirements.
Loose Corridor Handrails in Two Resident Halls
Penalty
Summary
The facility failed to ensure that its corridors were equipped with firmly secured handrails on both sides in two of the seven resident halls observed (400 and 500 halls). The facility’s policy titled “Safe and Homelike Environment,” revised November 14, 2025, states that the resident has the right to a safe, clean, comfortable, and homelike environment. During an observation of the 500 hall on March 25, 2026, at approximately 12:00 PM, the handrail affixed on the left side of the hall was found to be loose to the touch. A subsequent observation of the 400 hall on the same day at 1:25 PM revealed that the handrail affixed on the right side of the hall, near the therapy gym, was also loose to the touch. These observations demonstrated that the facility did not maintain securely affixed handrails in these corridors as required, resulting in noncompliance with its own policy and with 28 Pa. Code 201.18(b)(1) regarding management responsibilities for providing a safe environment.
Failure to Maintain Secure Handrails on Resident Hallways
Penalty
Summary
Surveyors identified a deficiency related to unsecured and missing handrails on two of the facility’s four floors. The facility’s own “Policy for Facilities Maintenance Program” dated 8/12/2025 stated its purpose was to ensure a well-structured preventative maintenance program to promote safety and functionality. A work order created on 1/18/2026 by the administrator documented that handrails on the second floor needed attention and were assigned a high priority. Despite this, observations on 2/17/2026 and 2/20/2026 showed approximately a twelve-foot section of handrails on the second floor detached and unsecured from the wall. Further observation on the third floor showed an additional approximately five-foot section of unsecured and missing handrails. A CMA reported in interview that the handrails had not been repaired for several months and described them as a safety hazard. The Resident Council President stated the facility was aware the handrails had not been repaired for several months and explained that some residents depend on securing their hands on the handrails for safety. The Maintenance Director reported noticing the inoperable handrails upon being hired on 1/23/2026 and confirmed the facility was aware the second- and third-floor handrails were not secured, without knowing why repairs had not been completed. The Nursing Home Administrator acknowledged awareness that the handrails needed repair and stated that the supplier was taking too long to deliver the materials.
Unsecured Corridor Handrails and Missing End Cap
Penalty
Summary
Facility staff failed to ensure that corridor handrails were firmly secured to the walls as required. During an environmental walkthrough of the facility on January 21, 2026, between 10:30 AM and 2:00 PM, surveyors observed that some handrails in the 1-South unit corridors were not firmly attached to the adjacent wall. Additionally, the handrail near room [ROOM NUMBER] was missing an end cap. These environmental deficiencies were confirmed by the Maintenance Director (Employee #19) at approximately 1:45 PM on the same day.
Unsecured Corridor Handrails on Two Units
Penalty
Summary
The facility failed to ensure that corridor handrails were firmly secured on the 300 and 400 units, potentially affecting all 32 residents residing on those units. Surveyors reviewed the facility census and observed that 12 residents lived on the 300 unit and 20 residents on the 400 unit. During an observation on the 300 unit, handrails outside several rooms were found to be loose and able to shift approximately 2 inches up or down, with one handrail shifting approximately 4 inches and showing visible loose screws coming out of the brackets. When light pulling pressure was applied to this handrail, it began to disconnect from the wall. The Maintenance Director observed these conditions, confirmed the findings, and stated that residents use the handrails for balance, safety, and to propel themselves down the hallway when in a wheelchair. On the 400 unit, additional observations showed loose, unsecured handrails outside multiple rooms, including areas across from the nurse's station and between various room pairs and a janitor closet. In one location, a hole approximately 5 inches tall by 3 inches wide was observed where the handrail bracket should be secured to the wall, and screws attaching the bracket to the wall were protruding approximately 1 inch from the wall. The Administrator and Maintenance Director observed and confirmed these conditions. When questioned, the Administrator asked if all handrails had been checked after the loose handrails were identified on the 300 unit, and the Maintenance Director stated that only the 300 unit handrails had been checked and fixed. Record review of the facility’s preventative maintenance policy dated 5/2025 showed that inspections of the facility’s handrails were not included as part of the preventative maintenance program.
Unsecured Hallway Handrails Not Repaired per Preventative Maintenance Policy
Penalty
Summary
The facility failed to ensure that hallway handrails on the 3rd floor were firmly secured as required by its own preventative maintenance policy. On a floor with 32 residents, surveyors observed that the handrail next to the bathroom and across from a resident room was unsecured, loose, and able to be displaced approximately 3 inches up or down. An LPN observed the loose handrail, confirmed it was loose, and stated it needed to be tightened, acknowledging that handrails are used for safety and to assist residents with gait abnormalities. The Maintenance Director later affirmed that the facility’s expectation is that handrails in common areas are secured and promptly repaired when needed, and that they are installed for resident safety and assistance. Subsequent observation showed that the same handrail next to the bathroom and across from a resident room remained unsecured and loose with approximately 3 inches of movement, and additional handrails across from and outside other resident rooms were also unsecured, loose, and able to be displaced approximately 3 to 5 inches, including one bracket with a screw protruding about 1.5 inches. Another LPN confirmed these observations and affirmed that handrails are for resident safety. The facility’s preventative maintenance policy directed staff to inspect all handrails throughout the facility for loosened fasteners or connectors and to make any needed repairs immediately. This deficiency arose from the presence of multiple unsecured and loose handrails in resident-accessible hallways, repeated observations of the same unresolved condition over several days, and the facility’s failure to adhere to its written preventative maintenance policy requiring immediate repair of loosened handrails.
Failure to Maintain and Secure Corridor Handrails
Penalty
Summary
The facility failed to ensure that all corridors had handrails and that existing handrails were securely affixed to the walls, as observed during multiple walkthroughs. Specific deficiencies included missing handrails between rooms and common areas, around the perimeters of nurses' stations, and in various hallways across the 100, 200, 300, and 400 halls. Additionally, several handrails were found to be loose, broken, or pulled away from the wall. These issues were directly observed by surveyors at different times throughout the facility. Interviews with the Maintenance Director and the Administrator revealed that the facility was aware of the missing and damaged handrails. The Maintenance Director stated that handrails were checked every three months and acknowledged the absence of necessary replacement parts, as well as the ongoing process of replacing plastic handrails with wooden ones. Both the Maintenance Director and the Administrator were not fully aware of the requirement for handrails to be present outside nurses' stations and on both sides of all corridors used by residents. The facility's area audit and preventative maintenance inspection listed handrails as an item for staff to inspect, but deficiencies persisted.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
