Evervella of Swansea: Antibiotic Error Causes Rehospitalization - IL
The resident, identified in inspection records as R2, was admitted to Evervella of Swansea with osteomyelitis, a bacterial infection of the bone that requires a full, uninterrupted course of antibiotics to treat. When she returned from the hospital on September 30, 2025, the nurse who transcribed her discharge orders recorded the antibiotic stop date as October 10. It should have been November 10.
Nobody caught it for weeks.
The error surfaced during a telehealth appointment with an infectious disease specialist on November 19. The nurse who had made the transcription mistake was in the room when the specialist reviewed R2's case. According to the Assistant Director of Nursing, identified in the report as V2, it was only then that staff realized the antibiotic had been discontinued a full month too early.
By that point, R2's osteomyelitis had returned.
The facility's pharmacist, identified as V11, was interviewed by inspectors on November 21. "Discontinuing the antibiotic early for osteomyelitis is a big deal," the pharmacist said. "That would be a significant medication error. That could lead to all sorts of problems."
The nurse practitioner who treated R2, identified as V12, was equally direct. "The incorrect transcription of the antibiotic for R2's osteomyelitis definitely contributed to her being re-diagnosed with osteomyelitis and needing further antibiotics," she told inspectors. "I would expect the orders to be transcribed correctly."
R2 was sent back to the hospital. She was readmitted to Evervella on November 12, 2025, arriving by ambulance accompanied by two emergency medical technicians. Hospital records showed she had a peripherally inserted central catheter, a PICC line, reinserted into her left upper arm. She was placed back on a combined regimen of intravenous and oral antibiotics, with a projected end date of December 24, 2025.
The Assistant Director of Nursing described the internal response in terms that were candid about the sequence of failures. "The nurse that took the orders transcribed the discontinue date of her antibiotics as 10/10/2025 and it was supposed to be 11/10/2025," V2 told inspectors. "We realized the error when R2 was in a telehealth meeting with the infectious disease specialist and the nurse that had incorrectly transcribed the orders was in the meeting with R2."
She added that R2's lab work had appeared normal in the interim, and that the infectious disease doctor had told the family they could decide whether to restart the antibiotic. "We didn't feel it was fair to put that decision on the family," V2 said, "so we sent R2 out to the hospital and there she was restarted on the antibiotic."
The facility told inspectors it had conducted education and training for staff and performed quality assurance reviews on all residents currently prescribed antibiotics, with particular attention to stop dates.
Inspectors assigned the violation a level of actual harm.
When R2 returned to Evervella on November 12, nursing staff documented her condition in detail. She was alert but confused, dependent on staff for all care needs, and had a hardened knot near her left elbow. Her right foot showed a hanging toenail on the second toe and a scab on the toe itself. A skin check performed on November 20 by the Assistant Director of Nursing and the wound nurse found that the same toe appeared calloused and darkened.
She had no complaints of pain upon return. Her call light was within reach. She ate well at lunch.
The inspection was conducted on November 21, 2025, in response to a complaint. The single violation, under federal tag F0760, covers the requirement that residents receive medications without error. The finding was cited at the actual harm level, meaning inspectors concluded R2 suffered a documented negative health outcome as a result of the mistake.
A one-digit transposition, October for November, and a woman with a bone infection spent a month without treatment, then spent weeks recovering from what the untreated infection had done to her, with a PICC line back in her arm and antibiotics running through Christmas Eve.
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.
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
EVERVELLA OF SWANSEA in SWANSEA, IL was cited for violations during a health inspection on November 21, 2025.
When she returned from the hospital on September 30, 2025, the nurse who transcribed her discharge orders recorded the antibiotic stop date as October 10.
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.