Axiom Healthcare of Harrisburg

In the surveyor’s words

From the most serious findings on record at Axiom Healthcare of Harrisburg, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 10, 2026

  Based 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.Findings include:R2's admission Record documented an admission date of 11/10/25 and included diagnoses of anxiety disorder, depression, and dementia. […]

• Actual harm, isolatedF686Mar 20, 2025

  Based 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). […]

• Actual harm, isolatedF686Jan 31, 2024

  Based 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. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE]. R1's Physician's orders dated 12/4/23-12/31/23 list some of R1's diagnoses as UTI (urinary tract infection), A-Fib (Atrial fibrillation), HTN (hypertension), seizure disorder, dementia, AKI (Acute kidney injury), and HLD (hyperlipidemia). […]

• Actual harm, isolatedF692Oct 15, 2021

  Based on record review, interview and observation, the facility failed to follow physician orders to provide nutritional supplements for a resident with significant weight loss for 1 (R9) of 2 residents reviewed for weight loss in the sample of 21. This failure resulted in R9 having a 10.89 percent (significant weight loss) over a 6-month time period. The findings include: R9's Profile Face Sheet documents that R9 was admitted to the facility on [DATE], and notes that R9 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF727Jun 3, 2026

  Based on interview and record review, the facility failed to staff a Director of Nursing (DON) and failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential of affect all 30 resident residing in the facility. Findings include: The facility schedule for April and May 2026 document on 04/04/26, 04/11/26, 04/12/26, 04/19/26, 04/25/26, 04/26/26, 05/02/26, 05/03/26, 05/10/26, and 05/23/26 the facility did not have a registered nurse working. On 05/28/26 at 3:55 PM, V1 (Administrator) stated they do not have a director of nursing and there are days that the facility does not have RN (Registered Nurse) coverage everyday. […]