Evervella Of Swansea
EVERVELLA OF SWANSEA in SWANSEA, IL — inspection on November 21, 2025.
Found 2 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
Provide care and assistance to perform activities of daily living for any resident who is unable.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform adequate incontinence care to 1(R1) of 4 residents reviewed for incontinence care in the sample of 5.
Findings include:R1's face sheet documents an admission date of 10/8/2025.
Diagnoses include Chronic Diastolic Congestive Heart Failure, Hepatic Failure, Nonalcoholic Steatohepatitis, Chronic Respiratory Failure, Pneumonia.R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive deficits. R1 requires maximum assist with rolling side to side and transfers. R1's care plan dated 10/23/2025 documents R1 has a venous/stasis ulcer related to peripheral vascular disease, to left and right lower extremities. R1 picks and scratches at skin.
Interventions include administer and monitor treatments as ordered.
Give medications for pain and minimize skin exposure to moisture from incontinence, wound drainage or perspiration. On 11/20/2025 at 8:06AM R1 lying flat in bed. R1 stated, I need to get up. I should've gotten up 2 hours ago. I know I am wet, and I need to get up.
Surveyor asked R1 if R1 had pushed call light. R1 stated, It won't do any good. It doesn't work.
Surveyor tested R1's call light and call light did not light up above R1's room door. On 11/20/2025 at 8:19AM V6, Certified Nursing Assistant, CNA, entered R1's room. V6 assisted R1 with rolling side to side and removing R1's wet incontinence pad and adult pull up.
Pad was very yellowed and soiled.
V6 then assisted R1 with a new adult pull up without performing any incontinence care. On 11/20/2025 at 8:25AM V6, stated, I do not usually work this hall, so I am unfamiliar with the residents.On 11/20/2025 at 3:20PM V2, Director of Nursing stated, I expect rounding to be done every 2 hours or sooner, so the residents needs are met.On 11/20/2024 at 3:30PM V1, Administrator, stated, V6 is a new employee. We just had orientation with her, and we go over and over incontinent care with all new employees.
Facility's Incontinent Care policy updated 6/17/2025 states Purpose is to prevent excoriation and skin breakdown, discomfort and maintain dignity.
Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every 2 hours and provided perineal and genital care after each episode.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of Swansea
100 Rosewood Village Drive Swansea, IL 62220
SUMMARY STATEMENT OF DEFICIENCIES
complaints of pain or discomfort at this time. R2's progress notes dated 11/12/2025 at 1:16PM documents R2 arrived at the facility at 11:40AM by way of EMS accompanied by two emergency medical attendants, EMT, attendants. R2 was readmitted and was reorientated to room. R2 is alert with confusion; mood is stable and dependent on staff for all care needs.
Per hospital nurse R2's diagnosis is osteomyelitis and R2 will be on IV and by mouth antibiotics until 12/24/25. R2 had no complaints of pain or discomfort upon return. R2 has a peripherally inserted central catheter (PICC) reinserted. PICC line to left upper arm which is intact.
Hardened knot near left elbow. No open areas to buttocks, old scar tissue in between left and right buttocks.
Old scar tissue under left buttocks.
Heels are intact, toenail to 2nd toe on right foot is hanging and toe has a scab.
Appetite was good during lunch. R2 is currently lying in bed with call light in reach.R2's hospital discharge paperwork dated 11/12/2025 documents R2 had external catheter placed on 11/12/2025 at 9:00AM. On 11/20/2025 at 12:00PM R2 was resting in bed with eyes open. V3, Assistant Director of Nursing, ADON, and V4, wound nurse performed skin check on R2. R2's second great toe appears calloused and darkened. On 11/19/2025 at 3:05PM V2 stated R2 came back from the hospital on 9/30/2025.
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. 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. R2's labs had been normal, and her white blood cell count had returned to normal.
The Dr even said it was up to the family if they wanted to restart the antibiotic. We didn't feel it was fair to put that decision on the family, so we sent R2 out to the hospital and there she was restarted on the antibiotic. We did some education, training, and quality assurance on all residents on an antibiotic and the stop dates. On 11/21/2025 at 8:50AM V11, Pharmacist, stated Discontinuing the antibiotic early for osteomyelitis is a big deal.
That would be a significant medication error.
That could lead to all sorts of problems.On 11/21/2025 at 9:35AM V12, Nurse Practitioner, NP, stated The incorrect transcription of the antibiotic for (R2)'s osteomyelitis definitely contributed to her being re-diagnosed with osteomyelitis and needing further antibiotics. I would expect the orders to be transcribed correctly.Facility's medication administration policy dated 6/1/2025 states To provide practice standards for safe administration of education for residents in the facility.
Medications will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner or as a consistent state law.
The licensed nurse must know the following information about any medications they are administering the drug's name, route of administration, action, indication for use and desired outcome, usual dosage and side effects.
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