Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Axiom Healthcare Of Harrisburg during CMS and state inspections, most recent first.
The facility failed to protect multiple residents from abuse by not adequately managing a resident with known aggressive behaviors and not updating his care plan after repeated incidents. A resident with severe dementia and a documented risk for aggression physically grabbed and held his roommate’s legs during the night, leading to a physical struggle. Later, the same resident became combative in the dining room, swung fists and a board, struck a CNA, and hit another resident on the head with facility signage. In a separate dining room incident, this resident rammed his wheelchair into another resident’s wheelchair, hit the resident in the back, yelled at him, and pulled his blanket, as reported by the resident and his family member. Staff interviews described this resident as commonly aggressive with frequent conflicts, yet the care plan interventions remained unchanged from their original initiation date, and the administrator delayed reporting one of the incidents despite receiving a detailed email from the family member describing the assault.
The facility failed to timely report an allegation of resident-to-resident abuse to the state agency as required by its abuse policy. A cognitively intact resident with COPD and other conditions reported that another cognitively impaired resident in a wheelchair rammed his wheelchair, hit him in the back, yelled at him, and pulled his blanket in the dining room, an event witnessed by the resident’s family member and another resident. The family member immediately informed an LPN, who assisted the alleged aggressor away and, according to the family member, instructed her to email the Administrator with a full account, which she did that evening. Despite this written report and later direct discussion with the family member, the Administrator did not notify the Department of Public Health within the required 24-hour timeframe and instead delayed reporting for several weeks, only submitting an Initial & Final report after receiving a subsequent complaint letter, resulting in a deficiency for untimely reporting of suspected abuse.
The facility failed to timely and thoroughly investigate an alleged resident-to-resident abuse incident. A cognitively intact resident reported that another resident with dementia rammed his wheelchair, hit him in the back, yelled at him, and pulled his blanket in the dining room, an event also described in detail by the resident’s family/POA in an email to the Administrator and later in a formal letter. Staff had previously observed the alleged aggressor being physically and verbally aggressive toward multiple residents. Despite this, the Administrator did not initiate an investigation when first informed of the allegation weeks after the event, and later submitted an initial and final report to the state on the same day without having interviewed all involved staff or the alleged victim, while still documenting that residents and staff had no concerns. These actions did not follow the facility’s abuse policy requiring immediate reporting, prompt investigation, and comprehensive interviews and documentation of all abuse allegations.
The facility did not ensure 8 consecutive hours of RN coverage each day, with gaps in coverage on multiple days when the DON was on medical leave and only one full-time RN was available. The Assistant DON confirmed that RN coverage was not always provided on weekends, and the facility lacked a formal staffing policy.
The facility did not ensure 8 hours of daily RN coverage on multiple occasions, as confirmed by review of nursing schedules and staff interviews. This affected all 35 residents and was acknowledged by the DON, a regional specialist, and the administrator, who also noted the absence of a staffing policy.
A resident with multiple pressure ulcers did not receive proper care and treatment as per physician orders, resulting in a Stage 4 ulcer not being treated for nine days. The facility failed to assess and document the resident's condition regularly, and staff were unaware of updated treatment orders. The Director of Nurses admitted to being behind on documentation, leading to inadequate care.
The facility failed to provide RN coverage for 8 consecutive hours daily, 7 days a week, as required. The schedule for February and March 2025 showed multiple days without RN coverage. The DON confirmed the lack of coverage on specific dates, and a resident expressed concerns about insufficient staffing. The facility's current census is 26 residents.
A resident with severe cognitive impairment and a history of falls did not have fall mats in place as per their care plan, despite multiple previous falls. The facility's failure to consistently apply fall prevention interventions was confirmed by an LPN, indicating a deficiency in adherence to the facility's Fall Prevention Program policy.
The facility failed to meet the required minimum living space of 80 square feet per resident in multiple occupancy rooms for eight residents. During a survey, ten rooms certified for four beds each were found to be below the required space per bed, with measurements ranging from 72.3 to 78.9 square feet per bed. Despite the deficiency, residents did not express concerns about the space, and some rooms were not fully utilized as four-bed rooms.
A resident with multiple health conditions did not receive doctor-ordered wound care twice daily as required. Despite the resident's cognitive awareness and communication with staff, the treatment was often administered only once per day. Staff interviews confirmed the inconsistency, and the facility administrator acknowledged the issue, suspecting undocumented refusals, although none were found in the records.
Failure to Protect Residents From Repeated Aggression by an Identified Assaultive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not adequately managing and responding to a resident with known aggressive behaviors. One resident (R2) had documented diagnoses of anxiety disorder, depression, and dementia, with a BIMS score of 6 indicating severe cognitive impairment. R2’s care plan identified a focus area of potential for aggressive behavior related to dementia, with interventions such as encouraging activities, monitoring labs, observing location and aggression level, and removing the resident from areas when aggression increased. These interventions were all initiated on the same date with no further additions or revisions despite multiple subsequent aggressive incidents involving other residents. The first substantiated incident occurred in R2’s room during the night, when staff heard yelling and found R2 on the floor holding onto the legs/foot of a roommate (R3), while R3 was hitting R2 in the head. R3 reported that R2 had come over and started “attacking” him by grabbing his foot and not letting go, and R3 stated he no longer wanted to room with R2. Both residents had dementia diagnoses, with R3’s BIMS score of 11 indicating moderate cognitive impairment. The facility’s investigation and report to the state agency characterized this as a resident‑to‑resident physical altercation and substantiated the allegation, but the care plan for R2 showed no new or revised interventions after this event. A second substantiated incident involved another resident (R4), who had schizoaffective disorder, anxiety disorder, dementia, and depression, with a BIMS score of 12 indicating moderate cognitive impairment. In the dining room, CNAs reported that an agitated R2 became combative, swung fists and a board removed from the wall, struck a CNA, threw a heavy Christmas decoration, and then hit R4 on the top of the head with facility signage. R4 described the event as a “shock” and stated that R2 “does crazy things.” The investigation form documented an injury location as the top of the scalp at the time of incident, although no visible injuries were later observed. Despite this second substantiated resident‑to‑resident altercation, R2’s care plan still reflected only the original interventions from the earlier date, with no documented additions or modifications to address the repeated aggression toward other residents. A third incident involved R1, who had COPD, panlobular emphysema, and dysphagia, and was cognitively intact with a BIMS score of 15. R1 and his family member (V9) reported that R2 approached R1 from behind in the dining room, rammed R2’s wheelchair into R1’s wheelchair, hit or punched R1 in the back, yelled at him, and pulled on his blanket until another resident verbally intervened. V9 stated she immediately reported the incident to the LPN on duty (V3), who then moved R2 away and, according to V9, instructed her to email the administrator with a full account, which V9 did that evening. Staff interviews indicated that R2 had a history of conflict and physical aggression with multiple residents, and that it was common for R2 to become aggressive. The administrator later acknowledged awareness of the prior substantiated incidents between R2 and R3 and between R2 and R4, but did not initially report the incident involving R1 and did not revise R2’s care plan beyond the original interventions, demonstrating a failure to identify patterns of abuse and to implement effective protective measures for other residents. The facility’s own Abuse Prevention and Reporting policy stated that residents have the right to be free from abuse and that the facility would identify occurrences and patterns of potential mistreatment, promptly investigate all allegations, and make necessary changes to prevent future occurrences. In practice, the facility substantiated multiple resident‑to‑resident altercations involving R2 but limited its response to minimal, case‑specific actions and did not update or expand R2’s care plan interventions after the initial date. The administrator also delayed reporting the incident involving R1 until after receiving a letter from R1’s family member to corporate, despite the family member’s contemporaneous email describing the assaultive behavior. These actions and inactions resulted in multiple residents being subjected to physical aggression by R2 without adequate, timely, and comprehensive protective measures in place, contrary to the facility’s abuse prevention policy and the requirement to keep residents free from abuse.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to the state survey agency and other required authorities, as required by its abuse reporting policy. One resident (R1), who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, panlobular emphysema, and dysphasia, alleged that another resident (R2), who had anxiety disorder, depression, dementia, and a BIMS score of 6 indicating severe cognitive impairment, physically assaulted him in the dining room. R1 stated that while he was sitting in his wheelchair after the evening meal talking with his family member (V9), R2 came up behind him, rammed R2’s wheelchair into R1’s wheelchair, and began punching him in the back. R1 reported that another male resident yelled at R2 to stop, after which R2 rolled away, and that his family member immediately went to get a nurse, leading R1 to assume the facility was aware of the incident. V9, R1’s family member, reported that she had previously been told by various staff that R2 could become physically aggressive and that staff had described R2 as combative, aggressive, and dangerous, with one staff member stating it was inevitable someone would get hurt with R2 in the building. V9 described that on the date of the incident, R2 rolled up behind R1 in the dining room, hit R1’s wheelchair with his own, and when R1 did not move, R2 began punching R1 in the back and pulling on his blanket while yelling at him. Another resident (R7) verbally intervened, and V9 went to get staff assistance. V9 stated that LPN V3 responded, assisted R2 back to his room, and instructed V9 to report the incident directly to the Administrator (V1). That same evening, V9 sent an email to V1 at 9:55 PM describing that R1 had been attacked or harassed twice that day by R2, including being pushed, slapped/hit, yelled at, and having his blanket yanked, and noted that V3 had asked her to report directly to V1. Despite this contemporaneous email report, the Administrator did not initiate timely external reporting. V1 later stated she was not aware of the 12/16/25 incident until 1/6/26, when V9 came to speak with her, and that she did not report the incident at that time because she believed it was unfounded. Email documentation shows that on 1/6/26, V9 forwarded the original 12/16/25 email to V1, copying the DON (V2), and explained that she had assumed the matter was addressed because the aggressor was absent from the facility the following days. The facility’s own Abuse Prevention and Reporting policy requires that when an allegation of abuse occurs, the resident’s representative and the Department of Public Health regional office be informed by telephone or fax, and that if there is suspicion a crime has been committed without serious bodily injury, a report to local law enforcement and the Department of Public Health must be made as soon as possible but within 24 hours of when the suspicion was formed. Contrary to this policy, the Administrator did not report the allegation to the Illinois Department of Public Health until 02/03/26, as documented on the Report to IDPH marked Initial & Final, which listed the incident date as 02/03/2026 and summarized that R1’s daughter had reported weeks after the incident that R2 grabbed R1’s blanket and hit his back. V1 acknowledged that she ultimately reported the 12/16/25 incident on 2/3/26 only after V9 sent a letter to corporate, demonstrating that the facility failed to timely report the abuse allegation in accordance with regulatory and policy requirements. The facility’s abuse policy further requires that an initial report to the Department of Public Health include the resident’s name, age, diagnosis, mental status, type of abuse reported, and the date, time, location, and circumstances of the alleged incident, and that a complete written final investigation report be submitted within five working days of the report. In this case, the initial external report was delayed for several weeks after the alleged incident and after the Administrator had been made aware of the allegation through direct communication from the resident’s representative. The Administrator’s decision not to report when first informed, based on her belief that the allegation was unfounded, and the failure to act upon the original 12/16/25 email describing a physical assault, are the actions and inactions that led to the cited deficiency for failure to timely report suspected abuse as required by the facility’s own policy and state and federal regulations.
Failure to Timely and Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely initiate and complete a thorough investigation of an alleged resident‑to‑resident abuse incident. One resident (R1), who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, panlobular emphysema, and dysphasia, alleged that another resident (R2), who was severely cognitively impaired with a BIMS score of 6 and had diagnoses including anxiety disorder, depression, and dementia, rammed his wheelchair into R1’s wheelchair and punched R1 in the back while they were in the dining room. R1 reported that a male resident yelled at R2 to stop, after which R2 rolled away, and that a nurse came and assisted R2 back to his room. R1 believed the facility was aware of the incident because his family member/POA (V9) went to get a nurse immediately after the event. V9 stated that on the date of the incident she witnessed R2 roll up behind R1 in the dining room, hit R1’s wheelchair, punch R1 in the back, yell at him, and pull his blanket, and that another resident verbally intervened. V9 reported that she went to get an LPN (V3), who then came to the dining room and assisted R2 away from R1. V9 said V3 instructed her to report the incident directly to the Administrator (V1), and that she sent an email to V1 that same evening describing that R1 had been pushed, slapped/hit, yelled at, and had his blanket yanked by R2. V9 further reported that she had been told by multiple staff that R2 was combative, aggressive, and dangerous, and that she had been actively trying to keep R1 away from R2. V9 later wrote a formal letter stating that the assault had been unreported and mishandled, and that to her knowledge no formal report had been filed and no meaningful safeguards had been implemented. Staff accounts and facility documentation showed that the facility did not promptly or thoroughly investigate the allegation as required by its abuse policy. V3 acknowledged being approached by V9 on the date of the incident but stated that V9 only reported verbal abuse and that she did not tell V9 to report to V1; V3 also confirmed that V1 later questioned her about when V9 had reported the incident. CNAs reported that R2 had a history of conflicts and physical aggression toward residents, including grabbing R1’s wheelchair and raising his fist toward others, but there was no evidence these observations were incorporated into a timely investigation of the specific allegation involving R1. The Administrator (V1) stated she did not become aware of the 12/16 incident until weeks later and did not start an investigation at that time because she believed the incident was unfounded. V1 reported that she only initiated an investigation on 2/3 after receiving a letter to corporate, and she submitted an initial and final report to the state on the same day, documenting that residents and staff were interviewed with no concerns identified. However, V1 admitted she had not yet interviewed all staff working at the time of the incident or the residents involved, had not spoken to R1, and could not explain how she could conclude there were no concerns without these interviews. This sequence of events demonstrates the facility’s failure to follow its own abuse prevention and reporting policy, which required immediate internal reporting, prompt initiation of an investigation, interviews of the reporter, involved residents, and relevant staff, and a complete written report within five working days of the allegation. The facility’s written Abuse Prevention and Reporting policy required that upon learning of a report of potential abuse, the Administrator or designee initiate an incident investigation, document all incidents, and ensure that any allegation involving abuse results in an investigation. The policy specified that the investigator must at minimum attempt to interview the person who reported the incident, anyone likely to have direct knowledge, and the resident if interviewable, and that a complete written report of the conclusion of the investigation be sent to the Department of Public Health within five working days. In this case, the Administrator acknowledged not initiating an investigation when first informed of the allegation weeks after the incident, and when an investigation was eventually started, it was incomplete at the time the final report was submitted. The final report to the state characterized the daughter’s report as being made weeks after the incident, stated that at the time of the incident she did not mention any hitting, and concluded that residents and staff interviewed had no concerns, despite the Administrator’s admission that she had not interviewed all relevant parties, including R1. These actions and omissions constitute the failure to timely initiate and complete a thorough investigation of an alleged resident‑to‑resident abuse incident as required by facility policy and regulatory expectations.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage each day, as required, for all 37 residents. Review of the November and December 2025 nurse schedules showed that there were multiple days in both months when no RN was present for the required 8 consecutive hours. Specifically, there was no RN coverage for 8 consecutive hours on several dates in November and on two dates in December. The Assistant Director of Nursing, who was the only full-time RN employed at the facility, confirmed that she worked Monday through Friday for 8 consecutive hours but that there was not always RN coverage on weekends. The Director of Nursing had been on medical leave since early November, and the facility did not have a staffing policy in place, instead stating that they followed regulations.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of daily Registered Nurse (RN) coverage as required, affecting all 35 residents in the facility. Review of the nursing schedules for June and July showed that there was no RN on shift for 8 consecutive hours on five specific dates. The Director of Nursing confirmed that there were no RN hours documented on those days, and both the Regional Reimbursement Specialist and the Administrator acknowledged the lack of required RN coverage. The Administrator also stated that the facility does not have a staffing policy, although it follows federal and state staffing regulations.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in a Stage 4 pressure ulcer not being treated as ordered by the physician for nine days. The resident, who was admitted with multiple pressure ulcers, including a Stage 1 pressure ulcer and two unstageable pressure ulcers, did not receive the necessary assessments and treatments as per physician orders. The resident's care plan included interventions such as administering medications, monitoring wound healing, and repositioning, but these were not consistently followed. The resident's physician orders included specific treatments for pressure ulcers on the coccyx, heels, and other areas, but these were not implemented or documented properly. Observations revealed that the resident's pressure ulcers were not assessed or measured regularly, and the treatments were not updated according to the wound specialist's recommendations. The facility's Director of Nurses admitted to being behind on the wound log and acknowledged that the most recent physician orders were not followed. Interviews with staff indicated a lack of communication and documentation regarding the resident's pressure ulcer care. The Licensed Practical Nurse responsible for the resident's care was unaware of the wound specialist's orders, and the Director of Nurses had not ensured that the orders were communicated and implemented. The facility's policy on pressure injury and skin condition assessment was not adhered to, leading to inadequate monitoring and treatment of the resident's pressure ulcers.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days per week, which is a requirement for long-term care facilities. This deficiency was identified through interviews and record reviews. The facility's schedule for February and March 2025 showed multiple days without RN coverage, specifically on 2/1, 2/8, 2/15, 2/22, 2/28, 3/1, 3/13, 3/14, 3/15, 3/22, and 3/29. During an interview on 03/19/2025, the Director of Nursing (V2) confirmed the lack of RN coverage on these dates and mentioned that they usually lack coverage on Saturdays, with some Sundays being covered by an RN who works as needed. A resident also expressed concerns about insufficient staffing at times. The facility's current census is 26 residents, all of whom could potentially be affected by this deficiency.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including dementia, depression, hypertension, and low back pain, experienced multiple falls over several months. Despite the implementation of various interventions such as physical and occupational therapy evaluations, frequent checks, and the use of alarms, the resident continued to fall. The care plan included the use of fall mats on both sides of the bed, but during an observation, it was noted that the mats were not in place, indicating a lapse in following the prescribed interventions. The facility's Fall Prevention Program policy aims to ensure resident safety by assessing fall risks and implementing appropriate interventions. However, the failure to consistently apply these interventions, as evidenced by the absence of fall mats during an observation, suggests a deficiency in the facility's adherence to its own policies. This oversight was confirmed by a Licensed Practical Nurse/Care Plan Coordinator, who acknowledged that the resident should have had fall mats on both sides of the bed, highlighting a gap in the supervision and implementation of fall prevention measures.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum living space of 80 square feet per resident in multiple occupancy rooms for eight residents. During a survey conducted from March 17 to March 20, 2025, the administrator measured ten rooms that were certified for four beds each, and all were found to be below the required space per bed. The measurements ranged from 72.3 to 78.9 square feet per bed, which is below the regulatory requirement. Despite the deficiency in room size, the residents occupying these rooms did not express any concerns about the space during interviews, and no issues were noted in the Resident Council meeting minutes from the past six months. The survey also noted that some rooms were not being used to their certified capacity, with fewer beds than certified, and some rooms were used for storage. For instance, one room had only two beds instead of four, and another had three beds and additional furniture, indicating that the rooms were not fully utilized as four-bed rooms. Despite these observations, the facility did not meet the regulatory requirement for room size, leading to the deficiency finding.
Failure to Administer Doctor-Ordered Wound Care
Penalty
Summary
The facility failed to provide doctor-ordered wound care for a resident, identified as R5, who was admitted with multiple diagnoses including Type 1 Diabetes Mellitus with diabetic kidney disease, end-stage renal disease, muscle wasting, and acquired absences of both legs below the knee. R5, who is cognitively intact and dependent on staff for personal care, reported that his wound care treatment, ordered to be administered twice daily, was often only performed once per day. Despite R5's communication with the nursing staff about the incomplete care, the issue persisted. The Physician's Order Sheet documented the requirement for twice-daily application of Santyl ointment starting from January 8, 2025. However, the Treatment Administration Record showed several missed treatments without any documentation of refusal by R5. Interviews with staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed the inconsistency in treatment administration. The facility administrator acknowledged the deficiency and suspected undocumented refusals, although no such documentation was found in R5's records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harrisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saline Care Nursing & Rehab | 0.5 mi | ★★★★★ | 0 | 0 |
| Carrier Mills Nsg & Rehab Ctr | 4.9 mi | ★★★★★ | 11 | 0 |
| Eldorado Rehab & Healthcare | 8.5 mi | ★★★★★ | 1 | 0 |
| Gallatin Manor | 16.4 mi | ★★★★★ | 19 | 0 |
| Integrity Hc Of Marion | 19.4 mi | ★★★★★ | 24 | 1 |
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