Health inspection·December 15, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to answer call lights in a timely manner for 6 (R1, R2, R3, R4, R5, and R6) of 6 residents reviewed for timely assistance in a sample of six. Findings include:1.R1's admission record documents an admission date of 111/21/25 with diagnoses including: nondisplaced comminuted fracture of shaft of right fibula, nondisplaced [NAME] fracture of right tibia, type two diabetes mellitus, hyperlipidemia, bell's palsy, and acute kidney failure. R1's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 15 indicating cognitively intact. R1's toilet transfer ability was documented as not attempted due to medical condition or safety concerns and chair to bed transfer as: partial/moderate assistance, and walk 10 feet as not attempted due to medical condition or safety concernsOn 12/12/25 at 12:48 PM R1 stated, the facility to the cushion out of her wheelchair and she had been up sitting in her chair for a while and her bottom hurt so she wanted to lay down so she would not be in pain and it took the staff over an hour before they would help her to bed. R1 stated, a few weeks ago she had to wait about three hours for a bed pan so she couldn't wait and soiled herself and had to stay like that for over an hour before someone came to assist her. R1 stated, there are other times she has waited 30 minutes to an hour before anyone would come. R1 stated, sometimes she will see the staff walk by her room when she has her call light on and they do not stop.2.R4's admission record documents an admission date of 11/26/25 with diagnoses including: chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure, peripheral vascular disease, muscle wasting and atrophy, and asthma. R4's MDS dated [DATE] documents a BIMS score of 14 indicating cognitively intact.On 12/12/25 at 12:53 PM R4 stated, sometimes she feels they do not have enough people to help. R4 stated, there are times it will take them a while to get to come assist them. R4 stated, she has put her call light on before so hopefully they would come assist R1 faster. R4 stated, the call light is on and they (the staff) just keep going on by (the room). 3.R2's admission record documents an admission date of 12/10/25 with diagnoses including: chronic diastolic heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic chronic kidney disease, persistent atrial fibrillation, obstructive sleep apnea, morbid obesity, abdominal aortic aneurysm, muscle wasting and atrophy, chronic kidney disease, and restless legs syndrome. R2 was alert to person, place and time at time of interview.R2's care plan documents a focus area of: the resident has an ADL (activities of daily living) self care performance deficit related to impaired balance and obesity with an intervention of encourage the resident to use bell to call for assistance with no date listed.On 12/12/25 at 12:56 PM R2 stated, the other night he put his call light on and he had to wait too long and had an accident and had to sit in it for a bit. R2 stated, he tried to hold it but he just could not wait any longer.4.R5's admission record documents an admission date of 07/03/25 with diagnoses including: stable burst fracture of T11-T12 vertebra, chronic kidney disease stage 4, atrial flutter, rheumatoid arthritis, obesity, Page 1 of 3 145620 145620 12/15/2025 Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cardiomegaly, diabetes mellitus, and reflex neuropathic bladder. R5's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact. R5's functional abilities document the ability to transfer from chair to bed and to transfer to the toilet is supervision or touching assistance. R5 toileting hygiene is documented as substantial/maximal assistance is needed.On 12/12/25 at 1:04 PM R5 stated, there are times she has had to wait a while for staff to answer her call light before usually it is more at night or the weekends. R5 stated, sometimes they will walk by and not acknowledge the light, depending of the staff member.5.R6's admission record documents an admission date of 10/14/25 with diagnoses including: cerebral infarction, middle cerebral artery syndrome, chronic kidney disease, type 2 diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction. R6's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact.R6's care plan documents a focus area of: impaired physical mobility with an undated intervention of assist resident in performing movement/tasks. This same care plan documents a focus area of: the resident had a cerebral vascular accident with an undated intervention listed as: monitor/document residents abilities for ADLs and assist resident as needed. Encourage resident to do what he/she is capable of doing for self.On 12/12/25 at 1:42 PM R6 stated, there are times in the nights he has had to wait over 30 minutes before they have come to assist him and there are other times that he has had to wait over an hour for someone to came and assist him at night.6.R3's admission record documents an admission date of 12/19/24 with diagnoses including: atherosclerotic heart disease of native coronary artery, diabetes mellitus due to underlying condition with diabetic nephropathy, atrial fibrillation, acute respiratory failure, acute and chronic respiratory failure, and overactive bladder. R3's MDS dated [DATE] documents a BIMS score 15 indicating cognitively intact. R3's functional abilities include: sit to stand as dependent, chair to bed transfer and toilet transfer as substantial/maximal assistance.R3's care plan documents a focus area of: the resident is at risk for falls relating to gait/balance problems, incontinence and amputation with undated interventions listed as: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 12/12/25 at 2:03 PM R3 stated, she has to go to the bathroom and she has already asked three CNAs (Certified Nurse Aides) for assistance and she has been told they will be back but she is still waiting and you can only wait so long. R3 stated, this (having to wait) happens all the time. R3 stated, it is not uncommon that she will have to wait 30 minutes or more before someone comes to assist her. She has had accidents because she just could not hold it anymore. R3 stated, there are some CNAs that could be more pleasant when they (the residents) need help. R3 stated, she can not help it that she can not just wait that long. R3 stated, there are times staff have walked by her room and not acknowledged her call light. R3 stated, she understands they are busy but they have to understand the residents including herself can not wait that long. R3 stated, sometimes they staff are on their phones in the hallway and they are waiting. R3 stated, she has brought this up in resident council several times because it never used to be this bad.On 12/13/25 at 11:56 PM V3 (Certified Nurse Aide (CNA)) stated, there is one CNA per hall for the night shift. V3 stated, he has approximately seven residents that require two persons to assist them on his hall. V3 stated, if he is already assisting another resident a different resident may have to wait 20 - 45 minutes depending on the care needed and how soon someone can assist him. V3 stated he has not walked by a resident's room with the call light on without telling them he will be back.On 12/14/25 at 12:08 AM V4 (CNA) stated, the hall she works at night usually has approximately 5 - 6 residents requiring two persons to assist. V4 stated, depending on the shift, it could be 25-30 minutes before she can get to the next resident if she is assisting 145620 Page 2 of 3 145620 12/15/2025 Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a resident, depending on the care needed and depending on how many are waiting. V4 stated, she has had residents have an accident before she could get there with a bedpan.On 12/14/25 at 12:18 AM V5 (CNA) stated, the hall she typically works at night has approximately 10 - 12 two person assist residents. V5 stated, she assists those individuals that their call lights have been on the longest and will assist them first then go to the next resident. V5 stated, she believes she has seen a 22 minute call light time before. Sometimes she may have to wait for someone to assist her. V5 stated, if the resident has their call light on, she will stop by the room and tell them she will be back when she can, she will not ignore it. V5 stated, she has had residents that have had accidents because she could not get there quick enough with a bed pan.On 12/14/25 at 7:43 PM V1 (Administrator) stated, her expectation is for call lights to be answered by all staff, if that staff member can not take care of that need then she would expect them to get the staff member that can. V1 stated, it would be her expectation for the call lights to be answered in approximately 5 minutes.The resident council minutes dated 10/28/25 documents a section titled, compliments/concerns/comments/suggestions: with a complaint listed as: there was a complaint about the CNAs not being helpful enough. These same minutes document a complaint of CNAs care for the residents they like and don't care for others and a complaint of: after meals there is no one on the halls to take residents to the restroom.The resident council minutes dated 10/28/25 document a section titled, compliments/concerns/comments/suggestions: with a complaint listed as: there was a complaint about the CNAs not being helpful enough.The undated facility policy titled, call light documents: to respond to residents' requests and needs in a timely and courteous manner. 145620 Page 3 of 3