Failure to Maintain Secure Handrails in Hallways
Summary
The facility failed to ensure that corridors were equipped with firmly secured handrails on each side, which increased the risk of falls for residents using the handrails for assistance with walking. During an observation in the Station 2 Hallway, a handrail was found to be broken and loose, and another was missing a curved piece of wood, exposing the metal bracket and screws. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged that broken and loose handrails posed a risk of injury to residents. The Maintenance Supervisor stated that the facility used the TELS System to notify the maintenance department of repair needs, and any staff member could access this system. Despite being notified of the broken handrails, the curved ends were obsolete and could not be replaced. The facility's policy and procedure documents emphasized the importance of maintaining a safe, clean, and comfortable environment, with regular facility rounds and oversight by the Executive Director, Director of Nursing, and Maintenance/Housekeeping Supervisor. However, the failure to maintain the handrails in good condition was a deviation from these policies.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Loose and Unattached Hallway Handrails: Second-floor hallway handrails were found loosely attached to the wall in multiple locations, and one handrail outside a resident room was unattached at one end and pulling away from the wall. Review of TELS work orders showed no report for the loose handrails, and the RM-D, MO-D, RN, and DON all confirmed the condition and that maintenance issues were expected to be reported through TELS.
A corridor handrail in the west hall just past the main entrance was observed to be loose and easily pulled away from the wall. A PTA and the DON confirmed the rail was unsecured, and the deficiency was identified as affecting all residents who use handrails.
Loose Handrail in First Floor Corridor: A handrail on the front side of the nursing station was observed to be loose to touch during an inspection of the 1st floor nursing unit. A housekeeper confirmed it was not secured properly and said he had known about it since Thursday but was unsure whether maintenance had been notified. An RN supervisor confirmed that handrails should be securely affixed to the walls.
Unsecured hallway handrail in North Station: The facility failed to keep a hallway handrail firmly secured to the corridor wall. An observation found the handrail was not secured, and the DON, MS, and IPN all stated it was not sturdy and should be secured for resident use. The MS reported that three of the mounts attaching the rail to the wall were broken.
Corridor Missing Handrails Near Exposed Electrical Equipment: The facility failed to ensure corridor handrails were present on both sides. An egress corridor leading to the outdoor picnic and smoking areas contained newly installed generator-related electrical equipment, including transfer switches, manual disconnect switches, and electrical panels, without guards on the corridor side. Residents were observed using the corridor, and the missing handrails were noted on the same side as the equipment.
Loose Handrail in Hall C: A hallway handrail between Rooms C3 and C4 was observed to be loose and wobbly rather than firmly secured to the wall. The Maintenance Supervisor stated he was not aware of the issue unless it was written in the maintenance logbook, and the work order log showed no related work orders. The facility policy states maintenance must keep the building safe and operable at all times.
Loose and Unattached Hallway Handrails
Penalty
Summary
The facility failed to ensure that handrails on the second floor were securely attached to the wall. During observation on 6/14/26 at 9:17 a.m., second floor hallway handrails were found loosely attached to the wall across from the elevator, across from the dining room and nursing desk, and between two resident rooms. One handrail outside a resident room was also unattached at one end and pulling away from the wall. During review of April, May, and June 2026 electronic work orders (TELS), there was no report of loose handrails. On 6/15/26 at 5:26 p.m., the regional maintenance director and maintenance operation director reviewed and verified the loose and unattached handrails. The maintenance operation director stated staff were expected to submit a TELS work order for anything needing repair or replacement, including loose and unattached handrails, but no such report was identified for January through June 2026. Staff interviews on 6/17/26 reflected that loose or unattached handrails were considered a safety concern and that staff were expected to submit TELS reports for maintenance issues, while the director of nursing confirmed that unattached and loose handrails were not safe.
Loose Corridor Handrail
Penalty
Summary
The facility failed to maintain corridor handrails at one identified location, with a rail along the west hall corridor just past the main entrance observed to be loose and easily pulled away from the wall. During the observation, the handrail was found to be unsecured, and a PTA later confirmed that the rail was loose and could be easily pulled away from the wall. The Director of Maintenance also confirmed that the rail was loose and needed to be repaired. The deficiency was identified as affecting all 77 residents in the census who use handrails.
Loose Handrail in First Floor Corridor
Penalty
Summary
The facility failed to ensure that its corridors were equipped with firmly secured handrails on one of two nursing floors, specifically the 1st floor. During an observation of the first floor nursing unit, the handrail affixed to the front side of the nursing station was found to be loose to touch. The housekeeper confirmed that the handrail was not secured properly and stated he had been aware of the issue since Thursday but was unsure whether maintenance had been notified. The Registered Nurse Supervisor also confirmed that handrails should be securely affixed to the walls.
Unsecured hallway handrail in North Station
Penalty
Summary
The facility failed to maintain a safe and secure handrail in one hallway at the North Station of the building. During observation on 5/6/26 at 8:14 AM, the handrail in the hallway was not firmly secured to the corridor wall. In an interview later that day, the DON stated the handrail was not secured to the wall and said that if a resident used it, the resident could lose balance and fall. The DON also stated the handrail should be secured to keep residents safe and prevent harm, and identified the MS as responsible for maintaining the facility in good condition and safe for residents. On 5/7/26, the MS observed the same hallway handrail and stated it was not sturdy for patients to use, was not fixed securely to the wall, and that three of the mounts attaching the rail to the wall were broken and should have been replaced. The MS stated he was responsible for ensuring all facility handrails were safe and sturdy for residents to use. During an interview on 5/8/26, the IPN stated handrails should be sturdy and secured to the wall and described the unsecured handrail as a safety issue for residents. The facility's undated Maintenance Department, Physical Environment, and Homelike Environment policies were reviewed and included maintaining a clean and safe facility, providing a safe and functional environment, and equipping corridors with firmly secured handrails on each side.
Corridor Missing Handrails Near Exposed Electrical Equipment
Penalty
Summary
The facility failed to ensure corridors were equipped with handrails on each side. During observation on 04/08/26 at approximately 9:59 A.M., emergency electrical equipment, including transfer switches, manual disconnect switches, and emergency electrical panels, was observed in the egress corridor without guards against accidental contact. The facility had recently installed a new generator with two transfer switches, manual override switches, and electrical panels in the first-floor egress corridor leading to the resident outdoor picnic and smoking areas. The equipment was mounted on the wall with fire-rated lumber behind it, but there were no guards on the side facing the corridor, and there were no handrails on the side where the equipment was installed. Residents were observed using this corridor, some accompanied and others unaccompanied by staff, to access the smoking area and outdoor picnic area. These findings were verified by the Regional Director of Operations and the Maintenance Director at the time of discovery.
Loose Handrail in Hall C
Penalty
Summary
The facility failed to ensure the hallway in C Hall between Rooms C3 and C4 had a handrail that was firmly attached to the wall. During an observation on 04/13/26 at 10:12 AM, the handrail in that hallway was noted to be loose and wobbly, rather than securely secured. The deficiency was identified for 1 of 6 hallways reviewed, specifically Hall C. During an interview on 04/14/26 at 1:35 PM, the Maintenance Supervisor stated he did not know about the handrail in C Hall or the water damage on the ceiling tiles, and said that if it was not written in the Maintenance logbook, then he did not know about it. The Maintenance Work Order Log from 3/16/26 to present contained no work orders related to the handrail between Rooms C3 and C4. The facility policy titled Maintenance Service states that maintenance service shall be provided to all areas of the building, grounds, and equipment, and that the maintenance department is responsible for maintaining the building in a safe and operable manner at all times.
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