Evercare of Swansea: Fall Prevention Failures - IL
The complaint inspection at Evercare of Swansea, completed August 27, 2025, found the 56-resident facility caused actual harm to residents by failing to provide adequate supervision to those at risk of falling. The violation affected a small number of residents, but inspectors classified the harm as real, not theoretical.
Two residents were at the center of the findings. For one, identified in the report as R3, staff acknowledged they were still trying to figure out a safer wheelchair arrangement at the time inspectors arrived. For another, R5, a nurse practitioner named in the report as V33 told inspectors on August 26 that if he was restless and resisting going to bed, staff couldn't force him, but they were expected to watch him closely. The inspection record does not indicate that happened.
The facility's own fall prevention policy required staff to evaluate residents upon admission, after any change in condition affecting balance or mobility, after a fall, and quarterly. The policy listed restlessness and combative behavior among the conditions that should trigger increased monitoring. It called for staff to examine the environment where a fall occurred, ask the resident what happened, and identify a root cause.
The director of nursing told inspectors her expectation was the same as the nurse practitioner's: a restless resident should be brought to a common area where staff could see them, or, if that would make things worse, monitoring should increase.
What the inspection found was the gap between those stated expectations and what actually took place on the floor, in the rooms, at the moments when residents needed someone watching.
R3's wheelchair was still being evaluated for safety weeks after concerns were identified.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
EVERCARE OF SWANSEA in SWANSEA, IL was cited for violations during a health inspection on August 27, 2025.
The violation affected a small number of residents, but inspectors classified the harm as real, not theoretical.
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.