Evercare of Swansea: Phone Access Denied to Residents - IL
The incident at Evercare of Swansea illustrates how basic communication rights disappeared when the facility failed to provide adequate phone access for its 23 residents.
The resident, identified as R2 in the August inspection report, became upset on July 25 when he wanted to use the phone but found a nurse occupying it. R2, who has moderate cognitive impairment, was admitted with depression, hypertension, and heart failure.
Three weeks later, the situation hadn't improved.
On August 20, R2 told inspectors that Licensed Practical Nurse V14 wouldn't let him use the phone at the nurse's station. "I have the right to use the phone," he said.
V14 defended her actions when questioned two days later. She acknowledged R2 wanted to use the phone but said she asked him to finish his call because three other residents were waiting in line. The nurse said she needed to make "important nursing calls."
The explanation revealed the scope of the problem. Multiple residents were competing for phone access with nursing staff who prioritized their own calls.
Director of Nursing V2 admitted the facility's failure during the inspection. "Phones for resident use are currently located at the nurse's stations," she said. "The nurses do need to make calls on these phones, but we should have phones available for these residents to use."
She added: "The Facility was wrong for that."
The admission contradicted the facility's own policy. Evercare's Resident Rights Policy, revised just two months earlier on June 1, explicitly states that residents have the right to use a phone in privacy.
Federal inspectors found the facility violated regulations requiring reasonable access to communication methods with privacy. The violation affected multiple residents beyond R2, though inspectors reviewed only three residents for communication access in their sample.
The phone shortage created a hierarchy where nursing staff calls took precedence over resident needs. Residents with depression, cognitive impairment, and other serious medical conditions were forced to wait while staff conducted business on the same phones.
For R2, the phone restrictions compounded his existing challenges. His medical record shows moderate cognitive impairment alongside depression and serious heart conditions. Access to communication with family or friends could provide crucial emotional support for someone battling depression in a nursing home setting.
The July incident that upset R2 occurred during a particularly vulnerable period. Progress notes from July 25 document his distress when he discovered the nurse using the phone he needed.
Nearly a month later, the same problems persisted. R2's August 20 statement to inspectors showed his understanding of his rights, even with cognitive impairment. His declaration that he had "the right to use the phone" demonstrated awareness that staff was denying him something fundamental.
The nurse's response revealed institutional priorities. V14's explanation about "important nursing calls" positioned her work needs above resident communication rights. Her mention of three residents waiting in line showed this wasn't an isolated incident but a systemic problem.
The Director of Nursing's acknowledgment that phones were only available at nurse's stations exposed the facility's inadequate planning. Placing resident communication access entirely within staff work areas guaranteed conflicts between nursing duties and resident rights.
Federal regulations require nursing homes to ensure residents have reasonable access to communication methods without being overheard. The regulation recognizes that private communication is essential to resident dignity and family connections.
Evercare's violation occurred despite having a current policy affirming phone privacy rights. The June policy revision showed administrators knew the requirements but failed to implement systems supporting them.
The inspection found minimal harm from the violation, but the impact on residents needing family contact during illness or emotional distress extends beyond regulatory categories. For residents like R2, dealing with depression while managing serious medical conditions, communication restrictions can worsen isolation and psychological distress.
The facility's admission that it was "wrong" came only after federal inspectors documented the systematic denial of phone access to residents who understood their rights but couldn't exercise them.
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: June 20, 2026 · Our methodology
EVERCARE OF SWANSEA in SWANSEA, IL was cited for violations during a health inspection on August 27, 2025.
The resident, identified as R2 in the August inspection report, became upset on July 25 when he wanted to use the phone but found a nurse occupying it.
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.