Deficient Handrail Maintenance in Facility
Summary
The facility failed to ensure that handrails on each resident hall were properly maintained, which had the potential to affect all residents. Observations on various units revealed multiple instances of loose or missing handrails. On the 100 South unit, several handrails were either detached, missing screws, or completely absent between rooms and outside key areas such as the soiled utility room and shower room. Similar issues were noted on the 100 Main, 200 Main, 300 Main, and 300 South units, with missing end caps and loose handrails being common problems. Interviews with facility staff revealed a lack of awareness and communication regarding the state of the handrails. The Interim Regional Director of Maintenance, who had just started, was unaware of the issues and had not yet assessed the equipment. The previous maintenance director acknowledged the problem and mentioned that replacement handrails were available but required a work order through the TELs system. The Director of Nursing and Administrator were aware of the missing handrails but not the damaged ones, indicating a gap in the facility's maintenance oversight and reporting processes.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Loose corridor handrails were observed in multiple areas, including the entrance corridor, near a bathing room, by an activity room, across from a dining room, and outside resident rooms. The MD acknowledged awareness of some loose handrails and said he was unaware of others; the safety inspection record for railings/grab bars in the lobby/entrance and hallways was left blank.
A hallway handrail was missing on the Ground-TCU unit, leaving an approximately 30-inch gap in the wall between the utility room and med room across from a resident room. The surveyor observed the opening, four holes where a handrail piece appeared to have been removed, and residents who were ambulatory and using walkers and wheelchairs. The Nurse Mgr and Regional LNHA both observed the area and acknowledged that a handrail was needed in that space.
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.
Loose Hallway Handrails: Handrails along the hallways were observed to be loose and easily moveable in multiple locations, including between rooms and outside several rooms. V11, the Maintenance Director, confirmed the condition of the handrails, and the Midnight Census Report documented 79 residents in the facility.
A corridor handrail on the first floor was not firmly secured to the wall, and a surveyor observed a section of wall adjacent to the elevator with the handrail missing and dry wall exposed where it had previously been attached. The LNHA stated the handrail had become dislodged, and the issue was identified on 1 of 4 floors during the initial tour.
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 Corridor Handrails
Penalty
Summary
Firmly secured handrails were not maintained in resident corridors, as multiple handrails were found loose during observations and walkthroughs with the Maintenance Director and Housekeeping Supervisor. At the front corridor near the building entrance, a several-foot-long rounded handrail was loose and drywall was falling from around the edges where screws and attachments were affixed to the wall. Additional loose handrails were observed beside the bathing room on the 100 hall, beside and across from the activity room in an open corridor area, across from the smaller dining room used by residents on the 400 halls, and outside the rooms of two residents. The Maintenance Director stated he was aware the handrail beside the bathing room on the 100 hall was loose, and he also acknowledged the front corridor handrail was loose with drywall falling out of the wall. He stated he was not aware that the handrails beside and across from the activity room, across from the smaller dining room, or outside the two resident rooms were loose. A record review of the facility's safety inspection documentation showed instructions to inspect the entire operational location quarterly and to immediately schedule and/or repair required repairs, but the inspection form for railings/grab bars in the lobby/entrance and hallways was left blank with no information entered.
Missing Hallway Handrail on Ground-TCU Unit
Penalty
Summary
A handrail was missing from the wall on the Ground-TCU Nursing Unit, creating a 30-inch gap between the utility room and the medication room across from Resident room G-9. During the annual recertification survey, the surveyor observed the gap and four holes in the wall where a handrail piece appeared to have been removed. Residents on the unit were observed to be ambulatory and using walkers and wheelchairs, and the unit census was 15 residents with a capacity of 17. The surveyor notified the Nurse Manager, who observed the missing handrail area and stated she would notify Maintenance. Environmental Services staff in the hall stated that there used to be a water fountain in that space. The Regional LNHA later observed the gap and the four holes and stated that a water fountain had been removed from the wall and that a handrail needed to be installed in that space. The LNHA also provided an email requesting a replacement handrail.
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 Hallway Handrails
Penalty
Summary
Firmly secured handrails were not maintained on each side of the hallways. On 06/01/2026 at 9:45 AM, the handrail between rooms [ROOM NUMBERS] was observed to be loose and moved easily. On 06/03/2026 at 10:00 AM, the handrail between rooms [ROOM NUMBERS] was again observed to be loose and moved easily, and additional handrails outside room eight, outside room [ROOM NUMBER], outside room [ROOM NUMBER], and outside room [ROOM NUMBER] were also observed to be loose and moved easily at 10:03 AM, 10:06 AM, 10:07 AM, and 10:09 AM. On 06/03/2026 at 1:55 PM, V11, Maintenance Director, confirmed that the handrails in these locations were loose and easily moveable. The Midnight Census Report provided by V1 Administrator on 6/1/26 at 9:30 AM documented that 79 residents resided in the facility.
Missing Corridor Handrail
Penalty
Summary
A corridor handrail on the first floor was not firmly secured to the wall, and the facility failed to maintain the physical environment in a safe condition. During the initial tour, the surveyor observed a portion of the wall adjacent to the elevator where a handrail was missing, with dry wall exposed where a previous handrail may have been secured. The deficient practice was identified on 1 of 4 floors. When informed of the finding, the LNHA stated that the handrail had become dislodged and that maintenance was working to install it. The facility policy titled Maintenance Services Policy stated that the building must be maintained in compliance with current federal, state, and local laws, regulations, and guidelines.
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.
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