Inspection·January 23, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide doctor ordered wound care for 1 of 3 (R5) residents reviewed for wound care in a sample of 9. Residents Affected - Few Findings included: R5's admission Record documented an admission dated of 11/27/2024 with diagnoses in part of Type 1 Diabetes mellitus with diabetic kidney disease, end stage renal disease, muscle wasting and atrophy and acquired absences of left and right legs below the knee. R5's MDS (minimum data set) dated 12/26/2024 documented R5's BIMS (brief interview for mental status) score of 15 out of 15 total which indicates R5 is cognitively intact. The MDS documented R5 is dependent on staff for all toileting, bathing and dressing tasks and needs partial/moderate assistance with all personal hygiene tasks. On 1/21/2025 at 11:00pm, R5 said he has developed a wound on his penis and his doctor has ordered his wound treatment to be done twice per day since 1/8/25, but usually the nursing staff only performs his wound care one per day. R5 said he has spoken with the nursing staff about getting his treatment done twice per day, but it still doesn't get completed. R5 said his wound is getting better despite his treatment not being done twice per day. R5's POS (Physician's order sheet) dated 1/1/25 through 1/31/25 documents the following order: 1/8/25 Santyl ointment 30 grams, cleansed penis with wound cleanser, pat dry, apply Santyl BID (twice per day). R5's TAR (Treatment administration record) dated 1/8/25 through 1/31/25 documented R5 missed the following treatments: 1/12/25 (6p), 1/13/25 (6p), 1/14/25 (6a), 1/14/25 (6p), 1/18/25 (6p) and 1/19/25 (6p). No further documentation was noted on the TAR as to why R5's has missed these treatments. A review of R5's progress notes for January 2025 did not document R5 refusing care. On 1/21/2025 at 2:00pm, V6 (Licensed Practical Nurse/LPN) said R5 has not been getting his treatments twice per day. V6 said she did not know why he's not getting the treatments as ordered by his doctor. V6 said if R5 refused his treatment, the nurse is supposed to document the refusal on the back of the TAR. V6 said she has not seen R5 refused to get his wound care done. On 1/21/2025 at 10:45am, V5 (Certified Nursing Assistant) said R5 tells her he does not get his wound care provided twice per day because the nursing staff won't do it. On 1/23/2024 at 10:45am, V1 (Administrator/LPN) said R5 should have been receiving his wound care twice per day as ordered by his doctor and did not know why R5 has been missing his treatment. V1 said she suspects R5 has been refusing and the staff are not documenting the refusals correctly. V1 (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 01/23/2025 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)