Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evervella Of Swansea during CMS and state inspections, most recent first.
The facility failed to respond to call lights in a timely manner, resulting in delayed assistance for residents needing toileting. A resident with multiple serious diagnoses, including heart failure, C. diff enterocolitis, gait abnormalities, and muscle weakness, reported that call light response times were long, worse at night and on weekends, and that a grievance she filed about this issue had not led to improvement. Another resident was observed with her call light on for about 25 minutes while CNAs passed meal trays before anyone responded, despite the facility’s policy and administrator’s statement that call lights should be answered promptly.
Two residents with mobility and toileting ADL deficits, but intact cognition, reported prolonged waits for assistance and nonfunctioning call lights, resulting in them being left in feces or urine and on bedpans for extended periods. One resident described call light responses taking up to an hour, with additional delays before a nurse arrived, and instances where staff turned off the call light and did not return. Another resident’s call light was confirmed not to work, leading her to yell for help at night for about 30 minutes despite hearing staff nearby. Resident council feedback noted call lights taking up to an hour to be answered, conflicting with facility policy requiring timely call light response and continuous accessibility.
A resident with fractures and Type 2 DM, who was cognitively intact and required partial to moderate assistance for toileting, reported that her bathroom call light had not worked for several days and demonstrated that activating the call light did not trigger the corridor signal. She stated that staff were supposed to check on her more frequently due to the nonfunctioning call system, but that night shift staff did not do so, causing her to yell for assistance. An LPN confirmed the call light was not working the prior day, the DON only became aware that morning, and the corporate maintenance supervisor acknowledged ongoing call light issues in multiple areas of the building, despite a facility policy requiring accessible call lights and prompt reporting and monitoring when defects occur.
Multiple residents with significant medical needs experienced prolonged wait times for staff to respond to call lights, resulting in discomfort, accidents, and unmet care needs. Interviews with residents and CNAs revealed that delays were common, especially during nights and weekends, and were attributed to staffing shortages and high care demands. Facility policy requires prompt responses, but both resident and staff accounts indicated this was not consistently achieved.
A resident with osteomyelitis, dementia, CKD, PVD, and CVA returned from the hospital on IV ceftriaxone, but the stop date was transcribed incorrectly on the MAR. The antibiotic was stopped early instead of continuing as ordered, and the error was later discovered during an ID telehealth visit. The resident was then sent back to the hospital for evaluation of osteomyelitis and returned with a PICC reinserted and new IV/PO antibiotic orders.
A resident with no cognitive deficits and maximum assist needs was found wet in bed, stating they should have gotten up hours earlier and that the call light did not work. A CNA removed a very yellowed and soiled incontinence pad and adult pull-up, then applied a new pull-up without providing incontinence care. The DON stated rounding should occur every 2 hours or sooner, and the Administrator said incontinent care is reviewed with all new employees.
Insufficient CNA staffing was identified after residents reported the facility was short staffed, with call lights sometimes going unanswered for 2 to 3 hours. Records showed the staffing schedule fell below the facility’s own staffing plan on multiple shifts, and a grievance had already been filed stating the new company was working employees too hard and the facility was short staffed.
Failure to Offer Snacks and Alternative Food Items: Residents reported that soda, hot chocolate, cookies, and other snacks were no longer offered, including in the evening and at night. A cognitively impaired resident and several cognitively intact residents said they were not given snacks and sometimes had to rely on family for food. Observation found no snack items in dry storage or the refrigerator, and dietary staff stated there was nothing available to pass out.
Failure to Maintain Resident Dignity: A resident with severe cognitive impairment and ADL dependence was observed in bed uncovered, with an incontinent brief on and her shirt pulled up under her breasts. Although the privacy curtain was pulled, the resident could still be seen from another bed once inside the room. The Administrator stated residents are expected to be treated with dignity, and the facility policy states it is intended to promote resident rights.
A facility failed to notify the resident’s POA of a change in condition after the resident was found on the floor and sent out for eval. The resident had multiple serious dx, significant ADL dependence, impaired UE/LE function, and used a wheelchair. Records and interview showed staff contacted the alternate family contact instead of the POA, despite the POA stating she had asked to be notified of any issues and the MDS/care plan coordinator stating the POA should be notified first.
Failure to protect residents from abuse during a remote-control altercation. Two cognitively intact residents, both using wheelchairs, argued over a TV remote when one resident tried to snatch it and grabbed the other resident's hand; the other resident scratched him, causing a skin tear and swelling. One resident had multiple chronic conditions including HF, AFib, DM2, anemia, HTN, and bradycardia, while the other had depression, heart disease, HF, and respiratory failure with hypoxia. The administrator later minimized the event as not serious despite the documented injury.
A resident with an indwelling Foley catheter and diagnoses including obstructive and reflux uropathy had no catheter care plan in the chart. The MDS showed the resident needed partial/moderate assistance with transfers and toileting, and a physician order directed monthly catheter changes. The facility could not provide a catheter care plan, despite its policy requiring a comprehensive person-centered care plan based on assessed needs.
Respiratory equipment was not properly cleaned or maintained for two residents. One resident on O2 had tubing/cannula with no date showing when it was last changed, despite a weekly-change policy. Another resident with OSA had CPAP/BiPAP equipment with no care plan, no set cleaning schedule, and the CPAP was observed uncovered with the hose and mask attached; staff stated cleaning was inconsistent with the manufacturer’s instructions and facility policy.
A facility failed to ensure insulin pens and a stock medication were properly labeled with readable expiration dates. Two residents had insulin pens that were not dated, and an LPN and the DON stated insulin pens and stock meds should have clear dates so staff know when they expire or should be discarded. A stock sodium chloride bottle on the med cart also had an expiration month that was not readable.
Meals Were Not Served in a Palatable or Timely Manner: Three residents reported poor food quality, smaller portions, and loss of soda, snacks, and other preferred items, with one resident stating breakfast was served late. Resident council minutes also documented repeated complaints about late meals, and the Administrator acknowledged resident complaints about reduced variety.
Failure to monitor antibiotic use and document UTI organisms. The facility did not maintain a facility-wide system to track antibiotic starts for residents treated for UTIs. For multiple residents, the infection surveillance log and EMR lacked organism documentation, while hospital records showed UTI treatment with antibiotics and, in some cases, urine cultures that were contaminated or not available. The DON and ADON/ICP stated they relied on hospital urine cultures to know what organisms were present and whether the antibiotic was resistant or sensitive, but the records were not consistently obtained or documented.
A resident with a history of falls and complex medical conditions experienced a fall and was not sent to the hospital for over two hours, resulting in a fractured ankle. Despite the resident's complaints of pain, the facility delayed medical intervention due to the POA's insistence on an in-house x-ray, which was unavailable overnight. The facility's failure to communicate effectively and adhere to its change of condition policy contributed to the delay.
The facility failed to maintain RN coverage for 8 consecutive hours daily, impacting 82 residents. No RN was on duty for two specific days, and staff acknowledged difficulties in hiring and retaining RNs, especially on weekends. The facility assessment and PBJ report highlighted ongoing staffing challenges and a lack of a staffing policy.
The facility failed to maintain an air gap for the ice machine, risking backflow contamination. The drainage hose was directly inserted into the drain without an air gap, potentially affecting all 82 residents as the ice is used for their drinks. The Dietary Manager was unaware of the backflow risk, violating the State Plumbing Code.
Two unlicensed staff members were hired as LPNs and allowed to administer medications under supervision without having passed their licensure exams. The facility lacked proper documentation and policies for Graduate Practice Nurses, leading to a violation of state regulations.
During a COVID outbreak, staff at the facility failed to follow CDC guidelines for PPE use. An LPN entered a COVID-positive resident's room wearing only an N95 mask, unaware of the need for full PPE, and later assisted in the dining room without changing PPE. A housekeeper also failed to wear eye protection while cleaning a COVID-positive resident's room. These actions contradict the facility's infection control policies and could impact all 82 residents.
A resident with severe cognitive impairment and a history of UTIs was observed receiving inadequate catheter care, with improper hygiene practices by a CNA. The resident's catheter drainage tubing was touching the floor, and contaminated wipes and gloves were used during the procedure. The facility's catheter care guidelines were not followed, contributing to the resident's ongoing UTI issues.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to follow physician orders for Marinol, which was on backorder. The facility did not notify the physician promptly, and the resident's care plan lacked nutritional interventions. Attempts to contact the medical director were unsuccessful, and confusion arose when a new order for Remeron was received, despite the resident already being prescribed it.
A facility failed to monitor and discontinue unnecessary psychotropic medications for a resident with dementia and major depressive disorder. Despite recommendations to discontinue PRN Haldol, the order remained active beyond the 14-day limit. The resident received multiple psychotropic medications without adequate documentation of necessity or effectiveness. Inconsistent monitoring and documentation of the resident's behaviors and medication effects were observed, contrary to the facility's policy on psychotropic drug use.
A hospice resident with Dementia and Parkinsonism did not receive appropriate care during a five-day Respite stay, resulting in significant behaviors and a leg injury. The facility failed to administer prescribed anxiety medications, leading to the resident's restlessness and injury. The resident was also found with multiple bruises, a significant leg wound, and dried stool upon discharge, indicating inadequate care and cleanliness.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights in a timely manner, as required by its call light policy. One resident, who uses a wheelchair, reported that she filed a grievance because it takes too long for staff to answer her call light and meet her needs. She stated that response times vary depending on which staff are working, that agency staff are the worst, and that delays are worse at night and on weekends. She reported having diarrhea and expressed concern that when she needs to use the bathroom, staff may not arrive in time, causing her to have an accident. She also stated that there had been no improvement in call light response times since she filed the grievance. Record review showed this resident has multiple diagnoses, including heart failure, malignant neoplasm of the bladder, enterocolitis due to Clostridium difficile, muscle wasting, abnormalities of gait and mobility, and muscle weakness, and requires supervision/touch assistance with toileting and partial/moderate assistance with transfers. Her care plan documents Clostridium difficile, and a grievance dated several days earlier documented her complaint about long call light wait times. During observation on another date, a different resident was seen with her call light on, stating she had turned it on to use the bathroom; the call light remained on for approximately 25 minutes while CNAs were passing meal trays before it was answered. The Acting Administrator/Regional Director of Operations stated that call lights should be answered as soon as possible, and the facility’s undated Call Light Policy states that resident call lights will be answered in a timely manner.
Failure to Ensure Functioning Call Lights and Timely Responses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had functioning call lights and timely responses to call light use, resulting in residents being left in soiled conditions and on bedpans for extended periods. One resident with hypertension, prediabetes, and post-polio syndrome, who was cognitively intact and required substantial/maximal assistance for toileting, reported being incontinent twice and left sitting in feces for over two hours on both occasions after being told staff were too busy serving supper. This resident also reported being left on a bedpan for more than an hour on more than one occasion, experiencing call light response times of up to an hour, and additional delays of up to another hour before a nurse arrived. The resident stated that staff sometimes entered, turned off the call light, and did not return. Another cognitively intact resident with type 2 diabetes and fractures of the left tibia and fibula, who required partial to moderate assistance for toileting, reported that her call light had not been working for 3–4 days. Observation confirmed that when she pressed the call light button, the corridor light did not illuminate. The resident stated that while day shift staff checked on her more frequently due to the nonfunctioning call light, night shift staff did not, and she had to yell for help during the night, including one occasion when she hollered for about 30 minutes before anyone came, despite hearing staff talking nearby. She reported being left in her own urine for an extended period in an undignified manner. Staff interviews showed inconsistent awareness of how long the call light had been nonfunctional, and resident council feedback documented complaints over the past 90 days that call lights could take up to an hour to be answered, contrary to the facility’s written policy requiring timely response and continuous availability of call lights to residents able to use them.
Failure to Maintain Functional Call Light System for Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to maintain a working call light system in a resident’s bathroom and bathing area. One resident with diagnoses including Type 2 diabetes and fractures of the left tibia and fibula was cognitively intact and required partial to moderate assistance for toileting, with a care plan noting an ADL self-care performance deficit related to right leg fractures. During an interview, the resident reported that her call light had not been working for 3–4 days and demonstrated that pressing the call light button did not activate the corridor light. The resident stated that, due to the nonfunctioning call light and the absence of a Maintenance Supervisor, staff were supposed to check on her more frequently, and that while day shift staff checked on her often, night shift staff did not, resulting in her having to yell for help during the night. Staff interviews and maintenance information further described the extent and duration of the call light problem. An LPN reported that the resident’s call light was not working on the previous day and that staff were checking on the resident at least hourly. The DON stated she became aware that morning that the resident’s call light was not working and believed it had stopped working that day. The Corporate Maintenance Supervisor acknowledged awareness that the resident’s call light was not working, was unsure how long it had been out, and reported having replaced a battery in part of the unit two days earlier. He also stated there had been issues with call lights in other areas of the building not working the prior week and that some call lights in empty rooms were currently not working. The facility’s undated Call Light Policy required that all residents able to use a call light have the system available and accessible at all times, that call bell system defects be promptly reported to Maintenance, and that hourly room checks occur until the system is repaired.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for all six residents reviewed for timely assistance. Multiple residents reported extended wait times for staff response after activating their call lights, with some instances exceeding an hour. Residents described situations where they experienced pain, discomfort, or soiled themselves due to the delay in receiving assistance, particularly with toileting and transfers. Several residents also observed staff walking past rooms with active call lights without stopping to help or acknowledge the request. Residents interviewed had significant medical conditions, including fractures, diabetes, chronic kidney disease, heart failure, and impaired mobility, requiring varying levels of assistance for activities of daily living. Despite care plans indicating the need for prompt assistance and the use of call lights, residents consistently reported delays, especially during night shifts or weekends. Some residents stated they had to wait for extended periods before being assisted, leading to accidents and prolonged discomfort. Certified Nurse Aides (CNAs) interviewed confirmed that staffing levels often resulted in delays, particularly when multiple residents required two-person assistance. CNAs reported that it was not uncommon for residents to wait 20 to 45 minutes, or longer, depending on the care needed and the number of residents waiting. Resident council minutes also documented complaints about insufficient CNA assistance and lack of staff presence after meals. The facility's policy requires timely and courteous responses to call lights, but this expectation was not met according to both resident and staff accounts.
Incorrect IV Antibiotic Stop Date Led to Early Discontinuation
Penalty
Summary
A resident with osteomyelitis, chronic kidney disease, cerebral infarction, peripheral vascular disease, and dementia returned to the facility from the hospital with orders to continue IV ceftriaxone through 11/10/2025. The resident was severely cognitively impaired, dependent for all activities of daily living, and required substantial to maximum assistance with turning and transfers. On readmission, the resident had a midline to the left upper arm and was documented as continuing IV antibiotics for osteomyelitis. The resident’s discharge paperwork listed ceftriaxone 2 grams IV daily with an end of treatment date of 11/10/2025, but the medication administration record entered the stop date as 10/10/2025. As a result, the IV antibiotic was stopped on 10/10/2025 instead of continuing as ordered. The resident later had a telehealth visit with Infectious Disease, during which staff discovered the transcription error and learned that the antibiotic had ended early. After the error was identified, the resident was sent to the hospital for evaluation related to osteomyelitis of the right foot. The resident returned with orders for IV and oral antibiotics through 12/24/2025 and had a PICC line reinserted. Staff interviews stated that the incorrect transcription of the antibiotic stop date contributed to the resident being re-diagnosed with osteomyelitis and needing further antibiotics.
Inadequate Incontinence Care and Delayed Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care for one resident who was admitted with diagnoses including chronic diastolic congestive heart failure, hepatic failure, nonalcoholic steatohepatitis, chronic respiratory failure, and pneumonia. The resident’s MDS documented no cognitive deficits and maximum assistance needed for rolling side to side and transfers. The care plan identified venous/stasis ulcers to both lower extremities, skin picking and scratching, and interventions to minimize skin exposure to moisture from incontinence, wound drainage, or perspiration. On observation, the resident was lying flat in bed and stated that they needed to get up, should have gotten up 2 hours earlier, and knew they were wet. The resident also stated the call light would not do any good because it did not work, and the surveyor tested the call light and found it did not light up above the room door. When a CNA entered the room, the CNA assisted the resident with rolling side to side and removing a wet incontinence pad and adult pull-up, which was described as very yellowed and soiled, then placed a new adult pull-up without performing incontinence care. The CNA stated she did not usually work that hall and was unfamiliar with the residents. The DON stated rounding should be done every 2 hours or sooner so residents’ needs are met, and the Administrator stated the CNA was a new employee and that incontinent care is reviewed with all new employees.
Insufficient CNA Staffing
Penalty
Summary
The facility failed to ensure there was an adequate number of CNAs working to provide care to residents. During interviews, a resident stated the facility is short staffed, another resident stated the facility is short staffed for CNAs and sometimes had to wait 2 hours for a call light to be answered, and a third resident stated that since the new company took over, staff have been cut down and that within the past 2 weeks he had to wait 3 hours for his call light to be answered because there were not enough staff. Record review showed the Facility Assessment, reviewed on 1/16/25, documented a staffing plan of licensed nurses 4/4/3 and CNAs 8-10/8-10/5-7 per shift per day. The CNA/Nurse Schedules documented staffing below that plan on 9/6/25 with 3 nurses and 3 CNAs, on 9/7/25 with 1 nurse and 4 CNAs, and on 9/13/25 with 3 nurses and 3 CNAs. A grievance filed on 6/30/25 stated the new company works employees too hard and the facility is short staffed. The facility's staffing policy states it is the policy to provide sufficient licensed and unlicensed nursing staff on each shift to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. The CMS 671 dated 9/23/25 documented 85 residents in the facility.
Failure to Offer Snacks and Alternative Food Items
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests, and the facility failed to offer snacks to residents. Multiple residents stated that since the new ownership took over, soda, fruit drinks, hot chocolate, cookies, and other snacks were no longer offered. A cognitively impaired resident stated the facility used to provide soda, candy, and cookies, but now does not offer snacks. Several cognitively intact residents reported they had not been offered snacks at any time, including in the evening or at night, and one resident stated her daughter had to bring her snacks from outside the facility. The resident council president stated the new owners took away hot chocolate, soda, and snacks and that residents were told there were no more snacks available. Another resident stated he gets hungry at night and has never seen snacks available, while another said she sometimes has to eat food she does not like because she gets hungry and no snacks are offered. Observation and record review showed no snacks in dry storage, no fresh fruit or other snack items in the refrigerator, and only one loaf of bread near the toaster. A dietary manager stated there was not enough budget for snacks and that items were ordered but removed, and a dietary aide stated no snacks were sent out because there was nothing available to give residents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity for R104, who was observed in bed uncovered with the blankets at the bottom of the bed, wearing an incontinent brief and with her shirt pulled up under her breasts. The privacy curtain was pulled, and the resident was not visible from the door, but once in the room it was possible to see around the curtain from bed one. R104's MDS documents severe cognitive impairment and the need for assistance with activities of daily living, and the care plan also documents that she requires assistance with activities of daily living. The Administrator stated that residents would be expected to be treated with dignity, and the facility's Resident Rights Policy states its purpose is to promote the exercise of rights for each resident.
Failure to Notify POA of Change in Condition
Penalty
Summary
The facility failed to ensure the POA was notified of a change in condition for one resident. The resident had multiple serious diagnoses documented, including acute respiratory failure, sepsis, malnutrition, hyponatremia, dementia, chronic conjunctivitis, NSTEMI, pneumonia related to inhalation of food and vomit, ARDS, repeated falls, and UTI. The resident’s MDS showed significant functional dependence, with assistance needed for most ADLs, impairments in both upper and lower extremities, and wheelchair use. The care plan documented that the resident was dependent on staff for emotional, intellectual, physical, and social needs and had immobility and physical limitations. The face sheet identified one family member as the POA and another as the alternate contact. Interview and record review showed that after the resident was found on the floor and sent to the hospital, staff notified the alternate contact rather than the POA. The POA later stated she had told the facility at a care plan meeting that she was the POA and wanted to be notified of any issues, and she reported that when her mother fell in June, she was not notified and her brother, the alternate contact, was contacted instead. The MDS/care plan coordinator stated the POA should always be notified first for any change of condition, and if the POA could not be reached, the alternate contact should be notified. The facility’s Change of Condition policy stated that medical care problems are to be communicated to the attending physician or authorized designee and family/responsible party in a timely, effective manner.
Failure to Protect Residents from Abuse During Remote-Control Altercation
Penalty
Summary
The facility failed to ensure abuse did not occur for two residents involved in a conflict over a television remote. R23 had diagnoses including depression, acute on chronic heart disease, heart failure, and acute respiratory failure with hypoxia, and her MDS documented that she was cognitively intact for decision making and used a wheelchair with lower-extremity impairments requiring substantial to maximal assistance for sit-to-stand transfers. During the incident, R23 stated she got into it with another resident over the remote and scratched him after he grabbed the remote from her hands. The initial report documented that R5 came over to R23 while she was watching television, grabbed for the remote, and sustained a skin tear to his arm from R23's fingernail; R23's finger was swollen but x-ray showed no fracture. R5 had diagnoses including heart failure, arthritis, chronic atrial fibrillation, type 2 diabetes mellitus, pain, anemia, essential hypertension, and bradycardia, and his MDS documented that he was cognitively intact for decision making and used a wheelchair. His care plan identified him as having potential to be verbally aggressive related to poor impulse control, including yelling at staff and residents and making statements about wishing he was dead. The final report stated that R5 attempted to snatch the remote from the table in front of R23, grabbed her right hand while trying to get control of it, and R23 scratched his left hand causing a skin tear. The administrator later stated the residents got into an argument over the remote but nobody was hurt and it was not anything serious, despite the documented injury and the facility's abuse prevention program requiring resident-to-resident altercations causing physical injury, mental anguish, or pain to be reported.
Failure to Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for R7’s indwelling catheter. R7 was admitted to the facility with a diagnosis of obstructive and reflux uropathy, unspecified, and the MDS dated 7/6/25 documented that the resident had an indwelling catheter and required partial/moderate assistance with bed mobility, transfers, and toilet transfer. A physician order dated 7/15/25 directed Foley catheter care with an 18Fr/10ml balloon and monthly changes on the 15th of each month. Survey review found no care plan for the catheter, and the facility was unable to provide one. During interview on 9/24/25, R7 stated that he does have an indwelling catheter. The facility’s policy on Care Planning stated that a comprehensive person-centered care plan is to be developed for each resident based on individual assessed needs.
Respiratory Equipment Not Cleaned or Maintained
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not maintaining oxygen and CPAP/BiPAP equipment as required. One resident with COPD and impaired gas exchange was observed receiving oxygen at 3.5 liters per minute by nasal cannula, but the oxygen tubing/cannula was not dated and there was no documentation showing when it had last been changed. The DON stated the oxygen tubing and humidifiers are to be changed weekly, and the facility policy required weekly changes of oxygen tubing, humidifiers, masks, and cannulas. A second resident with obstructive sleep apnea had a physician order for BiPAP at bedtime, and the MDS documented use of CPAP. The resident’s record did not contain a CPAP care plan, and the facility could not provide one. The resident stated that no one had cleaned the CPAP equipment since admission, and staff stated there was no set schedule for cleaning CPAP/BiPAP equipment. The CPAP machine was observed on the resident’s nightstand with the hose and mask attached and lying uncovered, while the manufacturer’s manual and facility policy described daily and weekly cleaning and maintenance steps for the water tank, hose, and mask.
Unlabeled Insulin Pens and Illegible Stock Medication Expiration Date
Penalty
Summary
The facility failed to ensure insulin pens and stock medication were labeled with legible expiration dates. For R35, the Physician's Order Sheet dated 9/2025 documented Humalog KwikPen 10 units subcutaneously three times daily for diabetes and Glargine insulin 42 units subcutaneously at bedtime for diabetes, but on observation the Humalog Kwik insulin pen and the Glargine insulin pen were both not dated. For R32, the Physician's Order Sheet dated 9/2025 documented insulin Aspart to be given per sliding scale three times daily for diabetes, but the Aspart insulin pen was also not dated when observed. The surveyors also observed the 400 hall medication cart and found a stock medication, sodium chloride 1,000 mg bottle, with an expiration month that was not readable and the year listed as 2025. V6, an LPN, stated insulin pens should be dated with the date they are opened so staff know when to discard them because they expire 30 days after opening. V2, the DON, stated insulin pens should be dated with the date of expiration so staff know when to discard them, and that stock medications should have readable expiration dates; if the date is not readable or has rubbed off, the nurse should throw the medication away. The facility's Medication Storage Policy, revised [DATE], states the purpose is to ensure proper labeling and expiration dates of medications and that medications should have an expired date on the label.
Meals Were Not Served in a Palatable or Timely Manner
Penalty
Summary
The facility failed to serve palatable, timely meals to 3 of 4 residents reviewed for nutritive value, appearance, palatability, and preferred temperature. One cognitively intact resident stated the food tasted horrible, that soda and snacks had been taken away, and that no snacks were offered during the day or evening, so the resident sometimes had to eat the food even though it tasted bad. Another resident with moderate cognitive impairment stated that since the new company took over, soda, candy, cookies, and snacks were no longer provided, the food was worse with smaller portions, and breakfast was late, being served at 8:45 AM instead of 8:00 AM. A third cognitively intact resident stated soda, fruit drinks at breakfast, and evening snacks had been cut out, and that the only food the resident liked was hot dogs and was getting tired of them. Resident Council minutes from multiple dates documented complaints that meals were being served late, and the Administrator stated the facility no longer had the same variety of food as before and that meal quality was one of the biggest complaints from residents. The facility policy stated food items would not be served unless palatable and pleasing to the eye.
Failure to Monitor Antibiotic Use and Document UTI Organisms
Penalty
Summary
The facility failed to develop, promote, and implement a facility-wide system to monitor antibiotic use for 3 of 5 residents sampled for antibiotic use. For one resident, the hospital after-visit summary documented a UTI and levofloxacin was prescribed, but the facility’s infection surveillance log listed symptoms and treatment without documenting an organism; the hospital urine culture later showed multiple organisms and probable contamination with a repeat culture suggested. The resident’s POS and MAR documented the antibiotic administration, but the EMR did not document an organism for the urine. For a second resident, the hospital after-visit summary documented a UTI and cephalexin was prescribed, while the facility’s infection surveillance log again listed symptoms and treatment without documenting an organism. The POS and MAR documented cephalexin administration, but there was no documentation of a urine culture in the hospital paperwork and no organism documented in the EMR. For a third resident, the hospital after-visit summary documented altered mental status, the facility’s infection surveillance log documented behaviors and antibiotic treatment with cefdinir, and no organism was documented on the log. The hospital paperwork for that resident showed a urine culture final report with mixed bacterial flora and contamination, but the EMR still had no organism documented for the UTI. The ADON/ICP stated she was responsible for ensuring all residents on antibiotics for UTIs had a urine culture in the medical record so the facility knew what organisms were in the building, and the DON stated the infection surveillance log did not have the organisms documented.
Delayed Medical Intervention for Resident After Fall
Penalty
Summary
The facility failed to seek timely medical intervention for a resident, identified as R39, who experienced a fall and was not sent to the hospital for over two hours, resulting in a fracture of her left ankle. R39 had a complex medical history, including Alzheimer's disease, dementia, osteoarthritis, and a history of falls, which placed her at increased risk for fractures. On the night of the incident, R39 fell out of bed, and despite her complaints of pain and visible injury, the facility delayed sending her to the emergency room due to the Power of Attorney's (POA) insistence on obtaining a STAT x-ray in-house, which was not available overnight. The nursing staff initially assessed R39 and noted a small lump on her left leg, with the resident expressing significant pain. The POA was contacted and requested an in-house x-ray, refusing to send R39 to the emergency room. The facility's nurse practitioner was not informed that STAT x-rays were unavailable overnight, which contributed to the delay in medical intervention. Despite R39's continued complaints of pain and her request to be taken to the hospital, the facility adhered to the POA's instructions until the Director of Nursing was notified and decided to send R39 to the emergency room. Upon arrival at the hospital, R39 was diagnosed with a closed fracture of the distal end of the fibula. The delay in seeking appropriate medical care was a significant oversight, as the facility's policy required notifying the physician and the resident's representative of any significant change in the resident's condition. The facility's failure to act promptly and communicate effectively with the nurse practitioner and the POA resulted in a prolonged period of pain and discomfort for R39.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, which is a requirement for the care of the 82 residents living in the facility. This deficiency was identified through a review of schedules and interviews with facility staff. Specifically, there was no RN coverage documented for the dates of 7/13/2024 and 7/14/2024. The Assistant Director of Nursing acknowledged the struggle to maintain RN coverage, particularly on weekends, and the Administrator admitted to the absence of an RN on the specified dates, citing difficulties in hiring and retaining staff. The facility's assessment highlighted a significant need for RNs to stabilize the nursing department, yet there was no staffing policy in place. The Payroll-Based Journal (PBJ) Report for the second quarter of 2024 also indicated concerns regarding RN coverage, contributing to a one-star rating for that fiscal quarter. Interviews with the Director of Nursing confirmed the absence of a staffing policy, further underscoring the facility's challenges in meeting the required RN staffing levels.
Ice Machine Lacks Required Air Gap
Penalty
Summary
The facility failed to maintain an air gap for the ice machine in the kitchen, which is a requirement to prevent potential backflow contamination. During an observation, it was noted that the white drainage hose from the ice machine was directly inserted into the drain hole without an air gap. This setup poses a risk of backflow from the sewage drain into the ice machine, potentially affecting the safety of the ice used for residents' drinks during meal services. The Dietary Manager acknowledged the issue upon observation, indicating a lack of awareness regarding the potential for backflow. The facility's failure to comply with the State Plumbing Code, which mandates an air gap for ice storage bins to prevent backflow, was documented. This deficiency has the potential to impact all 82 residents living in the facility, as the ice from this machine is used for their drinks.
Unlicensed Staff Administering Medications
Penalty
Summary
The facility failed to ensure that staff members hired as Licensed Practical Nurses (LPNs) had passed their required licensure exam before allowing them to work in the capacity of a license-pending graduate practice nurse. Two individuals, identified as V10 and V23, were hired for LPN positions without confirmation of a valid LPN license from the Illinois Department of Financial and Professional Regulation. Despite being unlicensed, they were allowed to administer medications to residents under the supervision of other nurses, which is not permitted by regulations. The Director of Nursing (DON) and the Administrator were unaware that V10 and V23 had not taken or scheduled their licensure exams. The DON admitted to allowing them to pass medications under supervision, believing it was permissible. Both V10 and V23 were observed wearing identification badges labeling them as LPNs, despite not having taken their licensure exams. They were also documented in employee files as LPNs, and were paid LPN wages, although they had not completed the necessary steps to obtain licensure. The facility did not have a job description or policy for the position of a Graduate Practice Nurse (GPN), and the Administrator relied on regulations without a clear understanding of them. The Assistant Administrator confirmed that background checks were conducted, but there was no documentation of completed LPN schooling for V10 and V23. The facility's actions were in violation of the Illinois General Assembly Public Act, which requires individuals to pass the licensure exam and meet other criteria before being employed as license-pending practical nurses.
Failure to Follow PPE Protocols During COVID Outbreak
Penalty
Summary
The facility failed to adhere to CDC Infection Control Guidelines during a COVID outbreak, as observed in multiple instances involving staff not wearing the appropriate Personal Protective Equipment (PPE). On one occasion, an LPN entered a resident's room, who was on droplet precautions due to a positive COVID test, wearing only an N95 mask without a gown or eye protection. The LPN was unaware of the resident's isolation status and subsequently assisted with breakfast in the main dining room without changing PPE. This oversight was acknowledged by the LPN, who admitted to not noticing the isolation sign on the resident's door. In another instance, a housekeeper was observed cleaning a COVID-positive resident's room while wearing a gown, gloves, and an N95 mask, but without eye protection. The housekeeper realized the omission after noticing the isolation sign on the resident's door, which indicated the need for droplet and contact precautions. The facility's policies, which were provided by the Administrator, outline the requirement for full PPE, including face shields or goggles, when dealing with residents on droplet precautions. These lapses in following established infection control protocols have the potential to affect all 82 residents in the facility.
Inadequate Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for an indwelling urinary catheter for a resident, leading to potential infection risks. During an observation, the resident was found with a catheter drainage tubing touching the floor, and the drainage bag was improperly stored in a privacy bag. A Certified Nursing Assistant (CNA) was observed performing catheter care without maintaining proper hygiene standards. The CNA used contaminated wipes and gloves, failed to maintain a clean/dirty field, and did not change gloves appropriately during the procedure. The resident, who has a diagnosis of urinary tract infection (UTI) and urine retention, was documented to have severe cognitive impairment and was dependent on toileting with an indwelling urinary catheter. The resident's care plan indicated a potential for UTIs due to the catheter use. The resident had a history of UTIs and sepsis, with multiple instances of cloudy urine and abnormal urinalysis results. The resident's medical records showed repeated hospital admissions and treatments for UTIs, including antibiotic therapy. The Director of Nurses (DON) stated that the facility uses a catheter competency guideline that requires staff to perform hand hygiene, use one wipe per swipe, and change gloves twice during catheter care. However, the observed practice did not adhere to these guidelines, as evidenced by the improper handling of wipes and gloves during the catheter care procedure. The facility's Foley Catheter Care Policy emphasizes the importance of using proper procedures to prevent UTIs, which was not followed in this instance.
Failure to Follow Physician Orders and Notify Physician
Penalty
Summary
The facility failed to ensure that physician orders were followed and that the physician was notified when orders could not be carried out for a resident diagnosed with multiple conditions, including rhabdomyolysis, anemia, and chronic kidney disease. The resident, who was moderately impaired for cognition, had a physician order for Marinol 2.5 mg to be administered twice daily to address appetite issues. However, the medication was on backorder, and the pharmacy was unsure of its availability date. Despite this, the facility did not notify the physician promptly about the inability to administer the prescribed medication. The resident experienced significant weight loss, triggering concerns from the dietary team. The resident's care plan did not address weight loss or nutrition, and the resident was noted to have poor meal intake and refusal of supplements. Although a new order for Remeron was received to replace Marinol, the resident was already prescribed Remeron, leading to further confusion. Attempts to contact the medical director were made, but no response was received. The facility's medication administration policy emphasizes administering medications per a standardized schedule, considering residents' preferences and quality of life, but this was not adhered to in this case.
Failure to Monitor and Discontinue Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to monitor medications properly, resulting in a resident receiving unnecessary medications. The resident, identified as R67, has moderately impaired cognitive skills and multiple diagnoses, including unspecified dementia and major depressive disorder. Despite recommendations from a consultant pharmacist to discontinue the PRN order for Haldol, the order remained active beyond the 14-day limit set by CMS guidelines. The resident was also receiving multiple psychotropic medications, including Buspirone, Quetiapine, Sertraline, Haloperidol, and Lorazepam, without adequate documentation of their necessity or effectiveness. Observations and interviews with staff revealed inconsistencies in the monitoring and documentation of the resident's behaviors and medication effects. The Behavior/Intervention Monthly Flow Record showed incomplete tracking of the resident's behaviors, with only sporadic documentation of restlessness and redirection. Hospice Plan of Care notes indicated varying levels of confusion, restlessness, and somnolence, but there was no clear evidence of the medications' benefits or the resident's improvement. The facility's policy on psychotropic drug orders emphasizes the need for appropriate use based on documented resident needs, avoiding unnecessary drugs, and ensuring informed consent for dosage changes. However, the facility did not adhere to these guidelines, as evidenced by the continued use of PRN Haldol without proper justification and the lack of comprehensive monitoring of the resident's condition and medication effects.
Failure to Provide Proper Care for Hospice Resident
Penalty
Summary
The facility failed to properly care for a hospice resident with Dementia and Parkinsonism who was admitted for a five-day Respite stay. The resident, who was dependent on staff for all Activities of Daily Living (ADLs) and mobility, did not receive appropriate care, including the administration of prescribed anxiety medications. This failure resulted in the resident experiencing significant behaviors and obtaining a leg injury. The resident's daughter reported that the facility did not administer the resident's anxiety medications, which were crucial for managing his restlessness and anxiety. Additionally, the resident was found to have multiple areas of bruising and a significant leg wound upon discharge, which was not adequately communicated to the family by the facility staff. The resident's care plan and Minimum Data Set (MDS) were not completed due to the short stay, and the facility's staff failed to follow best practices in managing the resident's condition. The resident's leg injury was initially described as a scratch, but it was later found to be much more extensive, with areas of blood and serosanguineous fluid. The facility's investigation revealed that the resident's leg had been rubbing against the bedrails, causing the injury. Despite the resident's high risk for skin impairments, the facility did not take adequate measures to prevent the injury or provide appropriate wound care. The facility's staff also failed to ensure the resident's cleanliness and proper nutrition during the stay. The resident was found with dried stool on him upon discharge, and only two out of the six nutritional supplement drinks provided were used. The facility's investigation confirmed that the resident's care was unacceptable, leading to disciplinary actions against the involved staff members. The Director of Nursing (DON) and Administrator acknowledged the deficiencies in care and the failure to meet the family's expectations for the resident's care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Swansea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evercare Of Swansea | 1.2 mi | ★★★★★ | 8 | 1 |
| Nexus Pavilion At Belleville | 1.7 mi | ★★★★★ | 8 | 0 |
| St Paul's Senior Community | 1.8 mi | ★★★★★ | 10 | 0 |
| Bria Of Belleville | 1.8 mi | ★★★★★ | 13 | 0 |
| Memorial Care Center | 1.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.