Evercare Of Swansea
EVERCARE OF SWANSEA in SWANSEA, IL — inspection on August 27, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
where calls can be made without being overheard for 1 of 3 residents (R2) reviewed for
facility on [DATE] with diagnoses including depression, hypertension, and heart failure.R2's Minimum Data Set, dated [DATE] documented R2 was moderately cognitively impaired.R2's 7/25/25 Progress Note documents R2 became upset because he wanted to use the phone, but the nurse was already using it.On 8/20/2025 at 9:10 AM R2 stated V14, Licensed Practical Nurse (LPN), would not allow him to use the phone at the nurse's station. He stated, I have the right to use the phone.On 8/22/25 at 10:27 AM, V14 stated R2 wanted to use the phone, but she asked him to finish up his call because there were three other residents waiting in line for the phone, and V14 needed to make important nursing callsOn 8/22/25 at 10:15 AM, V2, Director of Nursing (DON), stated phones for resident use are currently located at the nurse's stations.
The nurses do need to make calls on these phones, but we should have phones available for these residents to use.
The Facility was wrong for that.The Facility's Resident Rights Policy revised 6/1/25 documents residents have the right to use a phone in privacy.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145981 08/27/2025
Evercare of Swansea 1405 North Second Street Swansea, IL 62226
limited to receiving treatment and supports for daily living safely.
observation, interview, and record review, the Facility failed to provide adequate clean linen supplies
sample of 23.R7's Minimum Data Set (MDS) dated [DATE] documented R7 was cognitively intact.On 8/18/25 at 9:50 AM, R7 stated there are not enough towels and wash cloths in the Facility.
She likes to wash her face daily, so her family has to bring in wash cloths and towels in order for her to do that.R10's MDS dated [DATE] documented R10 was cognitively intact.On 8/22/2025 at 11:00 AM, R10 stated the Facility is always out of towels and wash cloths.
She has had to wait up to two weeks for a shower because staff tell her they do not have enough towels and wash cloths.R20's MDS dated [DATE] documented R20 was cognitively intact.On 8/21/25 at 11:35 AM, R20 stated there are never enough towels for bathing.R21's MDS dated [DATE] documented R21 was cognitively intact.On 8/22/2025 at 11:05 AM, R21 stated the Facility frequently runs out of towels and wash cloths and has been unable to take showers for weeks at a time for this reason.On 8/21/25 at 11:30 AM, V21, Certified Nursing Assistant (CNA) went to the Clean Utility closet where she would obtain linens.
There were no towels in the closet. On 8/21/25 At 11:40 AM, V8, CNA, went to the closet where she would obtain linens. It was the same closet shown by V21. V8 stated the towels are probably down in laundry.On 8/22/25 at 1:15 PM, V27, CNA, stated there has been a shortage of towels and wash cloths in the facility which she believes is due to some CNAs throwing them in the trash instead of rinsing them and putting them in the laundry.On 8/22/25 at 8:50 AM, V2, Director of Nursing (DON), stated towels are just disappearing in the Facility.
She is unsure if they are being thrown away, but suspects some residents are stashing them in their rooms.The Facility's Linen Handling-Nursing Policy reviewed 6/1/25 documents, Clean linen shall be stored in such a manner to prevent contamination.
Linens shall be maintained in the linen room or in enclosed or covered carts.
Laundry personnel shall be responsible for assuring adequate amounts of clean linen and personal clothing are available on each nursing unit.
145981 08/27/2025
Evercare of Swansea 1405 North Second Street Swansea, IL 62226
depend on the situation. If the resident was restless and up in their chair, she would expect them to
become more agitated, then they should increase monitoring due to increased behaviors.
She said
at 1:41 PM, V33, NP said she would expect the nursing staff to keep a close eye on him (R5) if he was restless and became combative due to not wanting to go to bed.
You can't force them to go to bed so she would expect the nursing staff to keep a close eye on him.The facility's fall evaluation and prevention policy, not dated, documented Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents.
Policy The facility will evaluate residents for their fall risk and develop interventions for prevention.
Upon admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation.
The goal is to prevent falls if possible and avoid any injury related to falls. It further documented RESIDENTS SHOULD BE EVALUATED FOR THEIR FALL RISK *On admission/re-admission to the home, *Following any change of status that may affect balance, mobility, or safety, *Following a fall, and *Quarterly. RISK FACTORS ASSOCIATED WITH A FALL Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications.
The following are examples of common intrinsic risk factors: *Gait and balance disorders, *Muscular weakness (particularly of the lower extremities), *Stroke, *Seizure disorder, and *Previous falls. It also documented Extrinsic risk factors for falls are part of the resident's environment and are most likely to be seen in areas such as the bedroom, bathroom, dining room, and hallways.
The following are typical examples of extrinsic risk factors: *Lack of or loose handrails. It also documented Fall Evaluation and Prevention Provide an elevated toilet seat and grab bars in the bathroom if indicated.
Refer resident to PT or OT. It further documented Evaluate the environment where the fall occurred, noting any factors that may have contributed to the fall (i.e., wet floor, socks without skid resistant pads, assistive device out of reach).
Ask the resident what happened prior to the fall or what may have caused the fall.
Root Cause.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility.
145981 08/27/2025
Evercare of Swansea 1405 North Second Street Swansea, IL 62226
services which include: Ensuring that the necessary care and services are person-centered and
socialization, independence, choice, and safety; Ensuring that direct care staff interact and
activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community.
Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's well-being.
Providing an environment and atmosphere that is conducive to mental and psychosocial well-being; and Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated.
ProcedureI.
Assess Causal Factorsa.
When a resident exhibits adverse behavioral symptom (e.g., crying, yelling, hitting, biting, etc.) licensed nursing staff will document those behaviors in the medical record, noting the time the behavior(s) occur, antecedent events, possible causal factors and interventions attempted.b.
Upon observing the adverse behavioral symptom, staff will do the following as indicted:i.
Ensure the safety of the resident as well as all other residents.ii.
Document notification of attending physicianiii.
Document notification of resident's family and/or responsible party about the change in behaviors and the attending physician response.iv.
Document the incident. c.
The charge nurse will assign a staff member(s) to monitor/shadow the resident as needed.i.
Such monitoring is for the protection of the resident as well as all others and is not meant to restrict their movement or mobility.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility.
145981 08/27/2025
Evercare of Swansea 1405 North Second Street Swansea, IL 62226
serve food in accordance with professional standards.
observation, interview, and record review, the Facility failed to store food in a manner that prevents
8:53 AM, in the refrigerator/freezer unit on the wall of the kitchen entryway, there was a large package of uncooked beef patties in the freezer stored directly above a box of popsicles. On 8/20/25 at 8:55 AM, in the standing refrigerator on the adjacent wall, there was a plastic tub of sour cream with manufacturer's Best By date of 7/2/25.
There was a clear container with hamburger patties that was not labeled or dated.
There was a container labeled banana pudding with a prepared date of 8/12 and no discard date.
There was a container labeled chocolate pudding with prepared date of 8/11 with no discard date.
There was a container labeled tuna with a prepared date of 8/13 and no discard date.
V19, Dietary Manager, stated someone did not write the discard date on the label. On 8/20/25 at 9:00 AM, in the dry storage room refrigerator, there was a package labeled turkey with a Use By date of 1/2/26.On 8/20/25 at 9:38 AM, R12's personal refrigerator in her room was inspected.
There was a carton of 2% milk with Use By date of 7/8/25.
There were two protein shakes with Use By dates of 3/5/24 and 7/4/24.
There was a Styrofoam container with a facility provided meal ticket inside dated 6/30/25. R12 stated staff do not have the time to clean out her refrigerator.R12's Minimum Data Set (MDS) dated [DATE] documented R12 was cognitively intact.On 8/22/25 at 3:16 PM, V1, Administrator, stated she expects dietary staff to follow food service policies.The Facility's Food and Supply Storage Policy dated 8/1/25 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner.
Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date.
All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product.The Facility's Long-Term Care Application for Medicare and Medicaid (CMS 671) dated 8/15/25 documents there are 56 residents living in the Facility.
145981 08/27/2025
Evercare of Swansea 1405 North Second Street Swansea, IL 62226
further documented k) Sweeps and wet mops every room in the facility every day (including
living in the Facility.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.