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
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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.
Corridor handrails were found with loose corner sections and uneven surfaces that created irregular gripping areas near multiple rooms and the men visitors bathroom. An engineer confirmed the handrails were not in good repair and that no immediate corrective action had been taken at the time of survey.
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.
Hallway handrails were found in disrepair and becoming detached from the wall on multiple units. A surveyor observed one railing move when leaned against and noted it was not secured on one side, and additional handrails were observed loose near stairwells, storage areas, the elevator, and resident rooms. The Mnt Dir acknowledged the condition of the handrails.
A hallway handrail on Hall A was observed without an end cap, leaving a sharp metal piece exposed, and it was not secured to the wall. An S9 service tech confirmed the issue, and the DON later confirmed the handrail should have been repaired.
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.
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.
Corridor Handrails Not Maintained in Good Repair
Penalty
Summary
Handrails in the facility’s corridors were not maintained in good repair. During a tour on 03/26/2026, surveyors observed handrails with loose corner sections and handrails with uneven surfaces that created irregular gripping areas. These conditions were seen next to multiple rooms and next to the men visitors bathroom. The engineer (employee #3) confirmed that the handrails were not in good repair and stated that no immediate corrective action had been taken at the time of survey.
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.
Hallway Handrails Not Secured to Wall
Penalty
Summary
Hallway handrails were not maintained in a safe operating condition on 3 of 4 units observed. During observation, a wall railing to the left of a resident room was noted to move slightly when the surveyor leaned against the wall, and further inspection showed the right side of that railing was not secured to the wall. Additional observations found hallway handrails in disrepair and becoming detached from the wall in multiple locations, including beside stairwell A on the second floor, near the storage room on the second floor south unit, near two resident rooms on the second floor north unit, by the elevator on the third floor north unit, and near two resident rooms on the third floor north unit. The Maintenance Director acknowledged that the handrails in these locations were in disrepair and becoming detached from the walls.
Incomplete and Unsecured Hallway Handrail
Penalty
Summary
The facility failed to ensure all corridors were equipped with a complete and secure handrail. On Hall A, the handrail was observed without an end cap, leaving a sharp metal piece exposed, and it was not secured to the wall. A service technician confirmed the handrail was missing the end cap and was unsecure, and the administrator later confirmed the Hall A handrail should have been repaired.
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.
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