Evercare of Swansea: Fall Leaves Resident With Head Laceration - IL
The resident, identified in inspection records only as R5, was found by a nurse in a prone position on the floor with an injury to the left side of his head. A nursing assistant documented the details: staff had made multiple attempts to transfer the resident to bed, he had refused each time and become combative, and he had been redirected several times before staff lost track of how he ended up on the floor.
Nobody saw him fall.
By 2:38 in the morning, a progress note documented that R5 was in the emergency room, waiting for stitches or staples to a laceration on his left forehead. Scans came back without fractures. He was resting. By 4:29 AM, another note confirmed the outcome: three steri-strips to the wound, then an ambulance ride back to the facility.
Federal inspectors cited the facility under F0689, the tag covering accident hazards and supervision, and classified the violation at the level of actual harm.
The facility's own fall prevention policy spelled out what should happen when a resident is known to be at risk. Evaluate the environment. Ask what happened. Identify root causes. Increase monitoring when behaviors escalate. The policy was not dated.
When inspectors interviewed the Vice President of Clinical Services on August 25, she said that if a resident was restless and up in their chair, she would expect staff to bring them to a common area, unless doing so would make them more agitated. In that case, she said, staff should increase monitoring because of the increased behaviors. She also mentioned that the facility was looking at changing R3's wheelchair to make it more comfortable and safer.
The nurse practitioner interviewed the following day was more direct. You can't force them to go to bed, she told inspectors. So she would expect nursing staff to keep a close eye on a resident who was restless and combative about not wanting to go to bed.
That is what did not happen.
The inspection was triggered by a complaint and completed August 27, 2025. At the time, 56 residents were living at the facility at 1405 North Second Street.
What the record shows is a gap between what the facility's own clinical leadership said should happen and what actually happened in the early hours of August 9. A resident who was known to be resisting care, who had already been combative with staff through multiple transfer attempts, was left in a chair without the close monitoring his condition required. The fall happened. The injury happened. The ambulance came.
R5 came back to the facility with three strips of tape holding his forehead together.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Swansea from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
EVERCARE OF SWANSEA in SWANSEA, IL was cited for violations during a health inspection on August 27, 2025.
The resident, identified in inspection records only as R5, was found by a nurse in a prone position on the floor with an injury to the left side of his head.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.