Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview, the facility failed to notify a medical provider of an out of therapeutic
range PT/INR (Prothrombin Time/International Normalized Ratio) lab result for one (R7) of five residents
reviewed for unnecessary medications in the sample of 18.
Residents Affected - Few
Findings include:
R7's Face Sheet documented an admission date of 12/4/23 and listed diagnoses including a history of
Cerebral Infarction and Unspecified Atrial Fibrillation. R7's Physicians Order Sheet for March 2024
documented an order dated 3/18/24 for Coumadin 4mg (milligrams) by mouth at bedtime Monday,
Wednesday, and Friday, alternating with Coumadin 3mg. by mouth at bedtime on Sunday, Tuesday,
Thursday, Saturday, and a 12/26/23 order for, PT/INR (to be drawn) weekly. A Lab Report dated 3/26/24
documented, Coagulation: PT-37.6 (reference range 9.8-12.2 seconds). INR-3.8 (reference range 0.9-1.2).
Handwritten on this document was, 3/26/24, 18:00. Called (V10/Physician's) office. Awaiting call back, and
3/27/24 14:25: Spoke with (V10's) Nurse, states (she) will call back (when) (V10) is in the office.
On 3/26/24 at 9:45am, R7 was in her room lying in bed. R7 was alert but oriented only to herself.
On 03/28/24 at 09:10 AM, V9 (Registered Nurse/RN) stated R7 gets her PT/INR drawn weekly to monitor
the Coumadin. V9 stated R7 is at baseline functioning and is not showing any side effects of coumadin
therapy. V9 stated V10 was in the building on 3/26/24 to sign order sheets and did not give any new orders
on R7. V9 stated they had not yet received the lab result when V10 was there. V9 stated staff
unsuccessfully attempted to contact V10 on 3/26/24 and 3/27/24. V9 stated he has not tried to call V10
today, but he will now do so.
On 3/28/24 at 9:26 AM, V2 (Director of Nurses/DON) stated V10 is also the facility's Medical Director. V2
stated staff should have tried calling V10's cell number or contacting the on call physician.
On 3/28/24 9:34 AM, this surveyor was present when V9 called V10's office. V9 told V10's staff he needed
to speak to V10 emergently and gave staff the lab results. V9 stated V10's staff consulted with V10 who
gave orders to hold one dose of the coumadin and resume it at 3mg. daily thereafter. V9 then documented
the interaction on a Telephone Order Sheet.
A Notification for Change in Resident Condition or Status Policy dated 12/7/17 stated, The facility and/or
facility staff shall promptly notify appropriate individuals (Administrator, Director of Nurses, Physician,
Guardian, Health Care Power of Attorney) of changes in the residents medical/mental condition and/or
status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician
when there has been: M. Abnormal lab findings.
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 4
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
03/28/2024
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 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview, the facility failed to hold quarterly Quality Assurance and
Performance Improvement (QAPI) meetings. This has the potential to affect all 19 residents residing in the
facility.
Residents Affected - Many
The Findings Include:
On 3/26/24 at 1:00 PM, V1 (Administrator) stated she is not able to provide any documentation of minutes
or attendance sheets for the facility's quarterly QAPI meetings. V1 further stated she started her
employment at this facility in September 2023 and no QA information was available because she has not
held a QAPI meeting since being employed.
During the survey, a review of facility records revealed no documentation quarterly QAPI meetings were
held. No meeting minutes or attendance sheets were found. The facility was unable to provide reproducible
evidence QAPI meetings had been scheduled or occurred.
The facility's QAPI Plan revised on 12/1/2022, documents Aspects of services and care are measured
against established performance goals. Key monitors are measured and trended on a quarterly basis. The
QAPI Committee analyzes performance to identify and follow-up on areas of opportunity.
The Long Term Care Facility application for Medicare and Medicaid dated 3/26/2024, documents 19
residents reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145978
If continuation sheet
Page 2 of 4
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
03/28/2024
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 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation and record review, the facility failed to provide at least 80 square feet of living space
for 8 of 8 residents (R2, R7, R9, R11, R12, R14, R15, R16) reviewed for room size in a sample of 18.
Findings include:
On 3/27/24 at 12:20 PM, this surveyor accompanied V3 (Maintenance Supervisor) for the purpose of
measuring the 10 resident rooms that are dually certified (Medicare and Medicaid) for 4 beds per room. The
10 rooms measured less than 80 square (sq.) feet (ft.) of living space per bed. The 10 room's
measurements are as follows:
room [ROOM NUMBER]: 311.5 sq. ft. (77.9 sq. ft. per bed)
room [ROOM NUMBER]: 302.8 sq. ft. (75.7 sq. ft. per bed)
room [ROOM NUMBER]: 305.7 sq. ft. (76.4 sq. ft. per bed)
room [ROOM NUMBER]: 304.4 sq. ft. (76.1 sq. ft. per bed)
room [ROOM NUMBER]: 310.2 sq. ft. (77.6 sq. ft. per bed)
room [ROOM NUMBER]: 289.6 sq. ft. (72.3 sq. ft. per bed)
room [ROOM NUMBER]: 304.1 sq. ft. (76 sq. ft. per bed)
room [ROOM NUMBER]: 315.7 sq. ft. (78.9 sq. ft. per bed)
room [ROOM NUMBER]: 314.6 sq. ft. (78.7sq. ft. per bed)
room [ROOM NUMBER]: 307.1 sq. ft. (76.8 sq. ft. per bed)
A Daily Roster provided by the facility and dated 3/26/24 documents that R2, R7, R9, R11, R12, R14, R15,
and R16 reside in the rooms listed above. There were no residents assigned to rooms 106, 109, 211 or
212.
During the survey from 3/26/24 to 3/28/24, no residents were observed to reside in rooms 106, 109, 211
and 212, confirming these rooms were unoccupied. room [ROOM NUMBER] was equipped with only 2
beds, an oversized recliner, 2 nightstands, and 2 dressers (rather than the 4 beds for which that room is
certified). Rooms 103, 104, 105, 107, 109, 110, 211, and 212 were each equipped with only 2 beds, 2
nightstands, and 2 dressers (rather than the 4 beds per room for which these rooms are certified).
Observations of the undersized resident rooms found the rooms adequate to meet the medical and
personal needs for the residents assigned to these rooms, as they were not currently being utilized as
4-bed rooms.
Inquiries regarding the size of these rooms during the survey from 03/26/24 to 03/28/24, found no concerns
or negative interviews from residents or families of residents who reside in the waivered
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145978
If continuation sheet
Page 3 of 4
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
03/28/2024
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 0912
Level of Harm - Potential for
minimal harm
rooms. During interview, on 3/26/24, R2, R7, R9, R11, R12, R14, R15, and R16 all voiced no concerns with
the size of their rooms during interviews.
Review of Resident Council meeting minutes from the past 6 months indicated no concerns related to the
size of the rooms.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145978
If continuation sheet
Page 4 of 4
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
FAQ · About this visit
Common questions about this visit
What happened during the March 28, 2024 survey of AXIOM HEALTHCARE OF HARRISBURG?
This was a inspection survey of AXIOM HEALTHCARE OF HARRISBURG on March 28, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AXIOM HEALTHCARE OF HARRISBURG on March 28, 2024?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.