Evercare Of Swansea

F 0576

Ensure residents have reasonable access to and privacy in their use of communication methods.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the Facility failed to provide reasonable access to a telephone in an area where calls can be made without being overheard for 1 of 3 residents (Resident R2) reviewed for communication with privacy in the sample of 23.Resident R2's Face Sheet documents Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including depression, hypertension, and heart failure.Resident R2's Minimum Data Set, dated [DATE REDACTED] documented Resident R2 was moderately cognitively impaired.Resident R2's 7/25/25 Progress Note documents Resident 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 Resident 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 Resident 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.

Residents Affected - Few

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare of Swansea

1405 North Second Street Swansea, IL 62226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the Facility failed to provide adequate clean linen supplies for 4 of 4 residents (Resident R7, Resident R10, Resident R20, Resident R21) reviewed for clean, comfortable, homelike environment in the sample of 23.Resident R7's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R7 was cognitively intact.On 8/18/25 at 9:50 AM, Resident 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.Resident R10's MDS dated [DATE REDACTED] documented Resident R10 was cognitively intact.On 8/22/2025 at 11:00 AM, Resident 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.Resident R20's MDS dated [DATE REDACTED] documented Resident R20 was cognitively intact.On 8/21/25 at 11:35 AM, Resident R20 stated there are never enough towels for bathing.Resident R21's MDS dated [DATE REDACTED] documented Resident R21 was cognitively intact.On 8/22/2025 at 11:05 AM, Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare of Swansea

1405 North Second Street Swansea, IL 62226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

after 911 call made due to fall. Resident refused to be placed in bed with staff reporting multiple attempts to transfer resident to bed with resident being combative. Resident was redirected several times per assigned staff resulting in resident refusing to leave position in chair. Nurse observed resident in prone position with injury to left side of head. All details of incident reported by CNA. DON notified of findingsR5's Progress Notes, dated 8/10/2025 02:38 AM, documented Resident being monitored for injury with report from hospital RN noting that resident is in the ER pending stiches/staples to laceration on left forehead. All scans returned with no fx (fracture) found. Resident is resting well awaiting discharge from ER. DON notified of all findings. Resident R5's Progress Notes, dated 8/10/2025 at 04:29 AM, documented Per local hospital ER Resident has been treated with three steri strips to the wound on left forehead. Resident is waiting for transport by ambulance back to facility. DON updated on progress of resident.Resident R5's emergency room Report, dated 08/09/25, documented the reason for his visit was due to a fall and his diagnoses were fall and head contusion. On 08/25/25 at 10:45 AM, V24, [NAME] President (VP) of Clinical Services said it would depend

on the situation. If the resident was restless and up in their chair, she would expect them to bring the resident out to the common area unless it would upset them more. If it would cause them to become more agitated, then they should increase monitoring due to increased behaviors. She said they are wanting to change Resident R3's wheelchair so it is more comfortable and safer for him.On 08/26/25 at 1:41 PM, V33, NP said

she would expect the nursing staff to keep a close eye on him (Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare of Swansea

1405 North Second Street Swansea, IL 62226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

including the effectiveness of psychoactive drugs.The goal of any behavior management process is to maintain function and improve quality of life. The goal of the Intradisciplinary Team (IDT) team is to promptly identify behavior management issues and develop an effective management program. It further documented When a resident displays adverse behavioral symptoms (e.g. Crying, yelling, hitting, biting etc.), Licensed nursing staff will assess the behavioral symptoms to determine possible causal factors, contact the attending physician, and implement non-drug interventions to alleviate the behavioral symptoms

before initiating any psychotherapeutic agent(s).The facility must provide necessary behavioral health care and services which include: Ensuring that the necessary care and services are person-centered and reflect that resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well- being; Providing meaningful 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare of Swansea

1405 North Second Street Swansea, IL 62226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the Facility failed to store food in a manner that prevents foodborne illness. This has the potential to affect all 56 residents living in the Facility.On 8/20/25 at 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, Resident 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. Resident R12 stated staff do not have the time to clean out her refrigerator.Resident R12's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare of Swansea

1405 North Second Street Swansea, IL 62226

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident room, all hallways, congregate areas, nursing station and offices at least once each day. b) Deep clean assigned bath/shower rooms, each resident room and all other rooms or areas at least once each month or per the cleaning schedule or as directed. It also documented d) Bath/Shower rooms are monitored for cleanliness and sanitation and the need for soap and paper products at least 4 times each shift. e) All floor surfaces are continually monitored for wet, dirty spots debris and other safety hazards.

Unsafe and unsanitary conditions are corrected immediately. It also documented i) Dining Rooms and other areas used for eating will be cleaned after each meal including wiping tables and chairs with a sanitizing solution. After breakfast floors in eating areas will be wet mopped completely; after other meals floors may be dry mopped completely and wet mopped where necessary. The policy further documented k) Sweeps and wet mops every room in the facility every day (including weekends and holidays) using a cleaning/sanitizing solution. 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.

Event ID:

Facility ID:

If continuation sheet