Axiom Healthcare of Harrisburg

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 4 (R1, R2, R3, and R4) of 7 residents reviewed for abuse out of a sample of 7. This failure would result in a reasonable person such as R3 and R4 feeling vulnerable, threatened, fearful or distressed due to R2's presence in the facility and not receiving adequate protection from aggressive behaviors.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely report a resident to resident abuse allegation for 1 (R1) of 7 residents reviewed for abuse in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely initiate and complete a thorough investigation of a resident to resident abuse allegation for 1 (R1) of 7 residents reviewed for abuse in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide 8 consecutive hours of the services of a Registered Nurse 7 days a week. This failure has the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage for the facility. This failure has the potential to affect all 35 residents living in the facility. Findings Include:The facility's Resident Daily Census Report document dated 8/27/2025, documents 35 residents residing in the facility. Review of the nursing schedules for June and July document that no RN was on shift on 6/8/2025, 7/4/2025, 7/5/2025, 7/6/2025 and 7/11/2025 for 8 consecutive hours. On 8/27/2025 at 2:22 PM, V2 (Director of Nursing) stated she is not aware if there had been any Registered Nurse (RN) coverage on 6/8/2025, 7/4/2025, 7/5/2025, 7/6/2025 and 7/11/2025. V2 stated, there are no RN hours documented on the schedule for those days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly assess, follow physician orders, and implement interventions to prevent and/or treat pressure ulcers for 1 of 1 (R78) residents reviewed for pressure ulcers in the sample of 26. This failure resulted in R78's Stage 4 pressure ulcer not being treated as ordered by the physician from 3/11/25 to 3/20/25 (nine days) and unstageable pressure ulcers to bilateral heels not being assessed and/or treated from 3/11/25 to 3/20/25 (9 days). Findings Include: R78's admission Record with a print date of 3/20/25 documents R78 was admitted to the facility on [DATE] with diagnoses that include hypertension, benign neoplasm of prostate, and vascular dementia with a diagnosis of muscle wasting and atrophy identified on 2/15/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days per week. This failure has the potential to affect all 26 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent falls for 1 of 2 (R7) residents reviewed for accidents in the sample of 26. Findings Include: R7's admission Record with a print date of 3/20/25 documents R7 was admitted to the facility on [DATE] with diagnoses that include dementia, depression, hypertension, and low back pain. R7's MDS (Minimum Data Set) dated 2/19/25 documents R7 has a severe cognitive impairment. This same MDS documents R7 has a history of falls without serious injury. R7's Investigation Report for Falls documents the following falls. 11/24/24 documents R7 was found lying on her back in the lobby. The intervention implemented was a physical therapy and occupation therapy evaluation and treatment. 12/20/24 documents R7 was found across from her room in the hall sitting on the floor. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to provide at least 80 square feet of living space for 8 of 8 residents (R3, R6, R12, R13, R18, R23, R24, and R80) reviewed for room size in a sample of 26.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview, the facility failed to maintain sinks in working order for 2 of 6 residents, (R1 and R6) reviewed for environment in the sample of 6.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide accurate skin assessments and/or ensure preventative treatment and services were implemented to prevent the development of pressure ulcers for 1 of 5 residents (R1) reviewed for pressure ulcers in a sample of 7. This failure resulted in R1 developing unstageable DTI's (deep tissue injuries) to the right and left heel with undetermined thickness.

Inspectors wroteBased on interview, observation, 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 failure has the potential to affect all 20 residents residing in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a Registered Nurse for eight hours a day, seven days a week: and failed to have a Registered Nurse to serve as a Director of Nursing on a full-time basis. This has the potential to affect all 21 residents that reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide sufficient dietary staff. This has the potential to affect all 21 residents that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a Director of Nursing for the facility. This failure has the potential to affect all 23 residents residing in the facility. Findings Include: On 05/9/23 at 10:20 AM, V1 (Administrator) stated the facility currently does not have a Director of Nursing (DON) and has not since December 2022. V1 states the facility has sought to hire a DON but been unsuccessful. V1 verified the accuracy of nursing schedules provided and stated the facility does not have any nursing waivers. On 5/11/23 at 2:00 PM, V10 (Registered Nurse) stated that they do not currently have a DON on staff. On 5/9/23 at 1:00 PM, V2 (MDS) stated that they have not had a DON for quite some time but that they are interviewing for the position. During the survey from 5/9/23 to 5/12/23, there was no DON observed working at the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a recapitulation of stay at the facility for 1 of 1 resident (R26) reviewed for discharge in a sample of 22. The Findings Include: R26 profile face sheet documents that R26 was admitted on [DATE] with a diagnosis of acquired absence of left leg, below knee. R26's nursing progress notes document that on 3/21/23 R26 was discharged from facility and left with husband in personal vehicle at 12:05. Discharge instructions and medications reviewed and sent with resident. A Discharge Evaluation was found in R26's medical record but was blank. On 5/11/23 at 10:00 AM, V2 (Minimum Data Set Coordinator) stated that there was not a completed discharge evaluation on R26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess residents blood sugar prior to administering fast-acting insulin for 1of 1 resident (R23) reviewed for insulin administration a sample of 22.

Inspectors wroteBased on interviews, observation, and record review the facility failed to provide at least 80 square feet of living space for 16 of 16 residents (R1, R5, R6, R7, R8, R9, R10, R11, R12, R15, R16, R17, R20, R21, R23, and R24) reviewed for room size in a sample of 22.