Inspection·December 14, 2023

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain effective pest control of rodents. This has the potential to affect all 23 residents residing in the facility. Residents Affected - Many Findings include: On 12/12/23 at 10:10 AM V2 (Registered Nurse/ RN) said the facility had a chronic mouse problem. V2 said R6's room had mice. V2 said she had reported the mice to V1 (Administrator). On 12/12/23 at 2:50 PM V5 (Certified Nursing Assistant/ CNA) said she had seen mice all around the facility. V5 said she had reported it to the nurses, V1, and V6 (Maintenance Director). V5 said she had heard there was a staff member who found a mouse in a resident's bed but could not recall which staff member or the specific resident. 1. R6's face sheet documented an admission date of 1/20/18. R6's Physician Order Sheet (POS) documented diagnoses including: hypertension, anxiety disorder, muscle weakness (generalized), cellulitis of right lower limb, difficulty in walking, venous insufficiency. R6's 11/3/23 Cognitive Assessment documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. On 12/12/23 at 10:24 AM R6's room was observed to have a large amount of mouse droppings around the perimeter of the room and under R6's bed. On 12/12/23 at 10:28 AM R6's room was set up like a sitting area and had a large amount of mouse droppings around the perimeter of the room. On 12/12/23 at 10:41 AM the hand washing sink in the kitchen was observed to have two mouse droppings on it. The dry good storage room was observed to have a large amount of mouse droppings and whitish-brown small, shredded material that looked like shredded cardboard. Mouse droppings were observed sparsely on the shelves of the dry good storage area. 2. R4's face sheet documented an admission date of 9/11/23. R4's POS documented diagnoses including: type 2 diabetes, atrial fibrillation, bipolar disorder, major depressive disorder, hypertension. R4's 11/2/23 MDS (Minimum Data Set) documented a BIMS score of 14, indicating R4 was cognitively intact. On 12/12/23 at 11:52 AM R4 said he saw a mouse in his room two days prior to this investigation. R4 said he had a mouse living in the closet in his room. R4 said he usually ate in his room and the mouse would come out at night to eat the crumbs he dropped during the day. R4 said he had told several (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145978 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Harrisburg 1000 West Sloan Street Harrisburg, IL 62946 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)