The resident, who has congestive heart failure and requires maximum assistance with basic movements, told an inspector on November 20 that she needed to get up and knew she was wet. "I should've gotten up 2 hours ago," she said from her bed at Evervella of Swansea.
When the inspector asked if she had used her call light, the resident replied, "It won't do any good. It doesn't work." Testing confirmed the call light failed to illuminate above her door.
Thirteen minutes later, certified nursing assistant V6 entered the room and helped the resident roll from side to side to remove her wet incontinence pad and adult pull-up. The pad was heavily yellowed and soiled.
V6 then put a new adult pull-up on the resident without performing any incontinence care.
The nursing assistant later told inspectors she was unfamiliar with residents on that hallway. "I do not usually work this hall, so I am unfamiliar with the residents," V6 said.
The resident's medical conditions make proper incontinence care critical. She has venous stasis ulcers on both lower legs related to peripheral vascular disease and picks at her skin. Her care plan specifically calls for minimizing skin exposure to moisture from incontinence.
Director of Nursing V2 told inspectors the facility expects staff to check residents every two hours or sooner to meet their needs.
Administrator V1 described V6 as a new employee who had recently completed orientation. "We just had orientation with her, and we go over and over incontinent care with all new employees," the administrator said.
The facility's incontinence care policy, updated in June, states its purpose is "to prevent excoriation and skin breakdown, discomfort and maintain dignity." The policy requires incontinent residents to be checked periodically every two hours and provided perineal and genital care after each episode.
The resident was admitted to Evervella in early October with multiple serious conditions including chronic respiratory failure, pneumonia, and liver failure. Despite having no cognitive deficits, she requires maximum assistance with rolling and transfers.
Federal inspectors found the facility failed to provide adequate incontinence care during their November 21 complaint investigation. The violation represents minimal harm or potential for actual harm to residents.
The inspection revealed a breakdown in basic care standards despite facility policies designed to protect resident dignity and prevent skin problems. The combination of a broken call light system and inadequate staff response left a vulnerable resident in unsanitary conditions for an extended period.
V6's admission that she was unfamiliar with residents on the hallway raises questions about staffing assignments and supervision of new employees. The administrator's emphasis on repeated training suggests ongoing challenges with ensuring staff follow established protocols.
The resident's situation illustrates how equipment failures can compound care deficiencies. With her call light inoperative, she had no way to summon help and remained in wet conditions despite being aware of her need for assistance.
The facility's policy explicitly requires both regular checking and thorough cleaning after incontinence episodes. V6's actions violated both requirements, changing soiled materials without performing the cleaning that prevents skin breakdown and infection.
For a resident with existing leg ulcers and a tendency to scratch her skin, prolonged exposure to moisture creates serious health risks. The care plan's specific instruction to minimize moisture exposure makes the nursing assistant's oversight particularly concerning.
The inspection found few residents affected by inadequate incontinence care, suggesting the problem may be related to individual staff performance rather than systemic facility-wide issues. However, the combination of equipment failure and inadequate care delivery points to broader oversight concerns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evervella of Swansea from 2025-11-21 including all violations, facility responses, and corrective action plans.