Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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 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.
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 | — | 2 | 1 |
| Nexus Pavilion At Belleville | 1.7 mi | — | 6 | 0 |
| St Paul's Senior Community | 1.8 mi | — | 8 | 0 |
| Bria Of Belleville | 1.8 mi | — | 10 | 0 |
| Memorial Care Center | 1.9 mi | — | 2 | 0 |
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