Loose Handrail Identified in Memory Care Hallway
Summary
A deficiency was identified when a 10-foot section of handrail between rooms A8 and A10 was found to be loose during an observation. The handrail could be moved back and forth approximately half an inch, with both screws in the middle bracket noted to be loose. The maintenance staff (MS) acknowledged the loose handrail and stated that it had been missed during daily rounds, known as Angel Rounds. The MS was unaware of how long the handrail had been loose and confirmed that it was his responsibility to ensure the facility was well maintained. The Director of Nursing (DON) also confirmed that handrails should be secure and that maintenance was responsible for their upkeep. Further observations revealed that 12 residents were present in the main area of the memory care unit, with one resident using the handrail to pull himself in his wheelchair, another present with a walker, and two residents without assistive devices. A CNA working in the unit was unaware of the loose handrail and believed that residents, primarily in wheelchairs, would not be at risk of injury from the loose rail. Review of the facility's policy confirmed that all handrails are required to be firmly secured and that routine maintenance is the responsibility of the maintenance department.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
The facility did not maintain a safe environment when the upper end of a stairway handrail on the right side going up from the parking lot to the first floor was found loose and easily movable during an observation with maintenance staff. The Maintenance Supervisor and Maintenance Assistant confirmed the handrail was not properly secured to the wall. Review of the facility’s “Quality of Life - Homelike Environment” P&P showed a requirement to provide a safe, clean, comfortable, and homelike environment, which was not followed in this situation.
Broken Hallway Handrail: A handrail on the 200 hall outside a room was observed broken and displaced about 3 inches vertically when pressure was applied. The Administrator and Maintenance Director confirmed handrails should be secure to the wall and agreed the handrail needed repair. The facility policy stated maintenance is responsible for keeping buildings and equipment safe and operable.
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.
Loose Stairway Handrail Not Secured to Wall
Penalty
Summary
The facility failed to maintain a safe environment by not securing the upper end of the stairway handrail on the right side as you go up from the parking lot to the first floor. During an observation and concurrent interview with the Maintenance Supervisor and Maintenance Assistant, the top end of this handrail was found to be loose from the wall and easily movable. Both maintenance staff confirmed that the handrail was loose. Record review of the facility’s policy and procedure titled “Quality of Life - Homelike Environment,” revised 1/10/25, showed that residents are to be provided with a safe, clean, comfortable, and homelike environment, including cleanliness and order, which was not met in this instance. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Broken Hallway Handrail
Penalty
Summary
The facility failed to maintain the handrails in a safe, secure, and functional condition on the 200 hallway. During an initial tour, the handrail outside of a room on the 200 hall was observed to be broken, and when pressure was applied it displaced approximately 3 inches vertically. Photographic evidence was obtained. During a follow-up observation with the Administrator and Maintenance Director, both confirmed that handrails should be secure to the wall and agreed that this handrail needed to be repaired. Review of the facility's Maintenance Service policy stated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner and in compliance with applicable laws, regulations, and guidelines.
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