F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on observation, interview and record review, the facility failed to provide Registered Nurse services
at least 8 hours a day, 7 days a week and failed to provide a full time Director of Nursing (DON). This affects
all 23 residents residing in the facility.
Findings include:
On 12/27/23 at 10:52 AM, V8 (Licensed Practical Nurse/ LPN) said she was the only licensed nurse
working on the floor. V8 said the facility did not currently have a Director of Nursing (DON).
The facility's December 2023 licensed nursing schedule documented no Registered Nurse (RN) coverage
on: 12/2/23, 12/8/23 12/9/23, 12/14/23, 12/15/23, 12/16/23, 12/21/23, 12/22/23, and 12/28/23.
On 12/29/23 at 11:23 AM, V1 (Administrator) verified there was no RN coverage in the facility on the above
listed dates.
On 12/29/23 at 8:32 AM, V1 stated the facility had not had a full time Director of Nursing (DON) since
12/6/23. V1 said no staff were interested in taking the position because they don't want to take call. V1 said
the facility had been advertising for the position online but no one had shown interest. V1 said there was a
possibility there was a nurse from a sister facility who had shown interest and it was a possibility she would
take the position in the future.
The facility's undated Facility Assessment Tool documented the facility required 1 full time RN to serve as
DON.
The facility Roster Matrix with print date of 12/19/23 documents there are 23 residents residing in the
facility.
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
12/29/2023
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to provide medical grade gloves for
resident care. This affects all 23 residents residing in the facility.
Residents Affected - Many
Findings include:
On 12/27/23 at 11:29 AM, V4 (Certified Nursing Assistant/ CNA) and V5 (CNA) said the facility had one
Personal Protective Equipment (PPE) storage room. V4 and V5 said the only gloves available from the PPE
storage room were vinyl food handler gloves. Boxes of food handler gloves were observed being used for
resident care around the facility.
On 12/27/23 at 11:57 AM, V1 (Administrator) said facility nursing staff had been using the vinyl food
handlers gloves for about a month due to the medical supply company having gloves on back order. V1 said
due to the facility not being able to acquire medical grade gloves, the food handler gloves were better than
no gloves. V1 said she had not tried to contact the local health department for assistance with acquiring
PPE.
On 12/27/23 at 1:03 PM, V7 (Health Department Director of Nursing) said the local health department no
longer was assisting facilities to acquire PPE. V7 said a facility was to contact the State of Illinois if they
needed assistance.
On 12/29/23 at 9:29 AM, V9 (Medical Supply Company Operator) said the facility had received a shipment
of gloves on 8/1/23 including 1 case of small gloves and 2 cases of extra-large gloves, again on 9/1/23
including 1 case of medium gloves, and again on 10/1/23 including 1 case of large gloves. V9 said the
facility had not ordered any gloves on back order and further stated he was not aware of any back orders
on any gloves provided by the medical supply company. V9 said he had checked the product numbers of
gloves previously ordered by the facility and all showed they were in stock.
On 12/29/23 at 8:59 AM, 5 resident rooms noted to be on contact and droplet precautions due to being
positive for Covid-19 had PPE bins outside their doors with boxes of food handlers gloves on them. The
PPE storage room contained a case of medium food handler gloves, a case of large food handler gloves,
and 9 boxes of small food handler gloves.
The facility provided an undated informational sheet from the food handler glove manufacturer that
documented in part . This product complies with FDA 21 CFR 175 as safe for food contact. This product is
general purpose and is not intended for medical use .
The facility Roster Matrix with print date of 12/19/23 documents there are 23 residents residing in the
facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145978
If continuation sheet
Page 2 of 2
