Evervella Of Swansea

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**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(Resident R1) of 4 residents reviewed for incontinence care in the sample of 5. Findings include:Resident 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.Resident R1's Minimum Data Set, MDS, dated [DATE REDACTED] documents Resident R1 has no cognitive deficits. Resident R1 requires maximum assist with rolling side to side and transfers. Resident R1's care plan dated 10/23/2025 documents Resident R1 has a venous/stasis ulcer related to peripheral vascular disease, to left and right lower extremities. Resident 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 Resident R1 lying flat in bed. Resident 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 Resident R1 if Resident R1 had pushed call light. Resident R1 stated, It won't do any good. It doesn't work. Surveyor tested Resident R1's call light and call light did not light up above Resident R1's room door. On 11/20/2025 at 8:19AM V6, Certified Nursing Assistant, CNA, entered Resident R1's room. V6 assisted Resident R1 with rolling side to side and removing Resident R1's wet incontinence pad and adult pull up. Pad was very yellowed and soiled.

V6 then assisted Resident 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.

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

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evervella of Swansea

100 Rosewood Village Drive Swansea, IL 62220

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 0760 Level of Harm - Actual harm Residents Affected - Few

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

complaints of pain or discomfort at this time. Resident R2's progress notes dated 11/12/2025 at 1:16PM documents Resident R2 arrived at the facility at 11:40AM by way of EMS accompanied by two emergency medical attendants, EMT, attendants. Resident R2 was readmitted and was reorientated to room. Resident R2 is alert with confusion; mood is stable and dependent on staff for all care needs. Per hospital nurse Resident R2's diagnosis is osteomyelitis and Resident R2 will be on IV and by mouth antibiotics until 12/24/25. Resident R2 had no complaints of pain or discomfort upon return. Resident 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. Resident R2 is currently lying in bed with call light in reach.Resident R2's hospital discharge paperwork dated 11/12/2025 documents Resident R2 had external catheter placed on 11/12/2025 at 9:00AM. On 11/20/2025 at 12:00PM Resident R2 was resting in bed with eyes open. V3, Assistant Director of Nursing, ADON, and V4, wound nurse performed skin check on Resident R2. Resident R2's second great toe appears calloused and darkened. On 11/19/2025 at 3:05PM V2 stated Resident 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 Resident 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 Resident R2. Resident 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 Resident 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 (Resident 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.

Event ID:

Facility ID:

If continuation sheet