Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to prevent significant medications errors by ensure
medications are available for 2 of 5 residents (R2, R5) reviewed for significant medication error in the
sample of 12.
Residents Affected - Few
Findings Include:
1. R2's Face Sheet documents an admission date of 10/402021 and diagnoses include Hypertension,
Chronic Obstructive Pulmonary Disease, Type 2 Diabetes.
R2's order sheet dated 10/25/2024 documents Metoprolol Tartrate Tablet 25 milligrams (mg), Give 1 tablet
by mouth two times a day related to Essential Primary Hypertension.
R2's Medication Administration Record (MAR) dated 3/1/2025-3/31/2025 documents Metoprolol Tartrate
25mg not administered on 3/1, 3/2 AM and PM, 3/3 AM, 3/7 AM and PM with no reason documented as to
why not given.
R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits and is independent
with transfers. Uses wheelchair for mobility.
R2's Care Plan updated 3/13/2025 R2 has Congestive Heart Failure and Hypertension. Intervention: Give
cardiac medications as ordered.
On 3/12/2025 at 12:00 PM R2 stated I did not get my heart meds for a few days.
On 3/12/2025 at 3:00PM V4, Licensed Practical Nurse, LPN, stated It looks like (R2) ran out of Metoprolol
at the end of February. It was ordered on 3/3 and came in 3/5. (V2, Director of Nursing, DON), just started
recently and is trying to get everything all caught up.
2. R5's Face sheet documents an admission date of 11/10/2023 with diagnoses of Congestive Heart
Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes.
R5's order sheet dated 1/27/2025 documents Warfarin tablet 1mg. Give 1 tablet by mouth at bedtime
related to Essential Primary Hypertension. Take with 2.5 mg= 3.5mg.
R5's order sheet dated 10/25/2024 documents Warfarin tablet 2.5mg. Give 1 tablet by mouth one time a
day for Prophylaxis Take along with 1 mg= 3.5mg.
(continued on next page)
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
Page 1 of 6
Event ID:
145981
Printed: 05/15/2026
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
145981
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare of Swansea
1405 North Second Street
Swansea, IL 62226
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 - Minimal harm
or potential for actual harm
R5's MAR dated 3/1/2025-3/31/2025 documents R5 missed doses of Warfarin on 3/5, 3/6, 3/7 both AM and
PM doses. No progress notes written regarding missed Warfarin.
On 3/13/2025 at 12:30PM R5 stated I was out of my Warfarin a couple weeks ago for a couple days. They
just said I was out.
Residents Affected - Few
On 3/13/2025 at 1:10PM V2, Director of Nursing, DON, stated I have been here for 3 weeks. I was not told
about missing medications. The only thing I can think of is we did not have lab services for a few days.
Maybe that is why (R5) did not get Warfarin, but that is not a good thing. I do not know about (R2) missing
meds either.
On 3/14/2025 at 10:40AM V14, Pharmacist, stated Missing Warfarin, an anticoagulant, is a big deal. That
would definitely be a significant medications error.
Undated facility policy states Medication will be administered by a Licensed Nurse per the order of an
Attending Physician or licensed independent practitioner or as consistent with state law. No medication will
be used for any resident other than the resident for whom it was prescribed. Medications must be given to
the resident by the Licensed Nurse to prepare the medication, to as consistent with state law.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145981
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
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
145981
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare of Swansea
1405 North Second Street
Swansea, IL 62226
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to provide information, obtain consents, and offer influenza
(flu) vaccination for 4 of 4 residents (R1, R2, R3, R5) reviewed for Influenza immunization in the sample of
12.
Residents Affected - Some
Findings include:
1. R1's Face Sheet documents an admission date of 2/7/2024 with diagnoses to include Dementia, Legal
Blindness, Hypertension, Bipolar.
R1's Minimum Data Set, MDS, dated [DATE] documents R1 is moderately cognitively impaired. R1 is
independent with transfers and requires supervision with ambulation.
R1's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
R1's paper chart documents vaccine on the following date: Influenza 10/19/2020.
There was no documentation in R1's medical record that the facility provided R1 with information on
influenza vaccination and obtained consent for vaccination.
2. R2's Face Sheet documents an admission date of 10/4/2021 with diagnosees to include Chronic
Obstructive Pulmonary Disease, Type 2 Diabetes, Hypertension, Chronic Kidney Disease.
R2's MDS dated [DATE] documents R2 has no cognitive deficits and is independent with transfers. Uses
wheelchair for mobility.
R2's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
R2's paper chart documents vaccine on the following date: Influenza 10/26/2021.
On 3/12/2025 at 12:00 PM R2 stated We did not get vaccines this winter. No flu, pneumonia, COVID or
RSV. R2 stated she did want these vaccinations.
There was no documentation in R2's medical record that the facility provided R2 with information on the flu
vaccination or obtained consent for this vaccination.
3. R3's Face sheet documents an admission date of 2/7/2024. Diagnosis include Chronic Obstructive
Pulmonary Disease, Dementia, Cirrhosis of the Liver, Epilepsy. R3's medical record documented R3 had a
Power of Attorney (POA).
R3's MDS dated [DATE] documents R3 is severely cognitively impaired.
R3's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145981
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
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
145981
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare of Swansea
1405 North Second Street
Swansea, IL 62226
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 0883
R3's paper chart documents vaccine on the following date: No influenza vaccine documented.
Level of Harm - Minimal harm
or potential for actual harm
There was no documentation in R3's medical record that R3's POA was provided any information on the flu
vaccination or given the opportunity to consent to the vaccination.
Residents Affected - Some
4. R5's Face sheet documents an admission date of 11/10/2023. Diagnosis include Congestive Heart
Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes.
R5's MDS dated [DATE] documents R5 has no cognitive deficits.
R5's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
R5's paper chart documents vaccine on the following date: Influenza 11/6/2023.
R5's medical record had no documentation that the facility provides information to R5 on the flu vaccination
or received consent from R5 to have the vaccination.
On 3/13/2025 at 11:20AM V2, Director of Nursing, DON, stated I just started 3 weeks ago. I saw where
consents for Influenza, COVID and Pneumonia were taken, but I did not see where the vaccines were
given.
On 3/14/2025 at 9:45AM V13, Regional Nurse Consultant, stated We just bought this building in December
of 2024. We were going to have a company come in and do the immunizations, but we weren't sure of
everyone's vaccine status. We are still working on it.
Undated facility policy states On admission, each resident or the resident's representative will be provided
with education regarding the benefits and potential side effects of the immunization. Once a consent is
signed indicating that they wish to receive the influenza vaccine, this consent is valid for the duration of the
resident's stay and the influenza vaccine will automatically be given annually. Each resident is offered an
influenza immunization October 1 through March 31 annually, unless the immunization is medically
contraindicated, or the resident has already been immunized during this time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145981
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
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
145981
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare of Swansea
1405 North Second Street
Swansea, IL 62226
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to provide information, obtain consents, and offer COVID-19
vaccinations to 4 of 4 residents (R1, R2, R3, R5) reviewed for COVID-19 immunization in the sample of 12.
Findings include:
1. R1's Face sheet documents an admission date of 2/7/2024 with diagnoses to include Dementia, Legal
Blindness, Hypertension, Bipolar.
R1's Minimum Data Set, MDS, dated [DATE] documents R1 is moderately cognitively impaired. R1 is
independent with transfers and requires supervision with ambulation.
R1's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
R1's paper chart documents vaccine on the following date: COVID 19 11/6/2023.
There was no documentation in R1's medical record that the facility attempted to provide R1 with
information on the COVID-19 vaccination or obtain consent for this vaccination.
2. R2's Face sheet documents an admission date of 10/4/2021 with diagnoses to include Chronic
Obstructive Pulmonary Disease, Type 2 Diabetes, Hypertension, Chronic Kidney Disease.
R2's MDS dated [DATE] documents R2 has no cognitive deficits and is independent with transfers. Uses
wheelchair for mobility.
R2's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
R2's paper chart documents vaccine on the following date: No COVID 19 vaccine documented.
On 3/12/2025 at 12:00 PM R2 stated We did not get vaccines this winter. No flu, pneumonia, COVID or
RSV. R2 stated he/she wanted the vaccination.
There was no documentation in R2's medical record that the facility provided R2 with information regarding
the COVID-19 vaccination or the facility obtained consent for this vaccination.
3. R3's Face sheet documents an admission date of 2/7/2024 with diagnoses to include Chronic
Obstructive Pulmonary Disease, Dementia, Cirrhosis of the Liver, Epilepsy. The Face sheet documents R3
has a Power of Attorney (POA).
R3's MDS dated [DATE] documents R3 is severely cognitively impaired.
R3's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145981
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
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
145981
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare of Swansea
1405 North Second Street
Swansea, IL 62226
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 0887
R3's paper chart documents vaccine on the following date: COVID 19 11/6/2023.
Level of Harm - Minimal harm
or potential for actual harm
There was no documentation in R3's medical record the facility provided R3's POA with information on the
COVID-19 vaccination or obtained consent for R3 to be vaccinated.
Residents Affected - Some
4. R5's Face sheet documents an admission date of 11/10/2023. Diagnosis include Congestive Heart
Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes.
R5's MDS dated [DATE] documents R5 has no cognitive deficits.
R5's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries
regarding any vaccines.
R5's paper chart documents vaccine on the following date: COVID 19 11/6/2023.
There was no documentation in R5's medical record the facility provided R5 with information on the
COVID-19 vaccination or obtained consent from R5 to be vaccinated.
On 3/13/2025 at 11:20AM V2, Director of Nursing, DON, stated I just started 3 weeks ago. I saw where
consents for Influenza, COVID and Pneumonia were taken, but I did not see where the vaccines were
given.
On 3/14/2025 at 9:45AM V13, Regional Nurse Consultant, stated We just bought this building in December
of 2024. We were going to have a company come in and do the immunizations, but we weren't sure of
everyone's vaccine status. We are still working on it.
Undated facility Immunization policy states To minimize the risk of residents acquiring, transmitting, or
experiencing complications from (COVID-19).
The facility shall provide pertinent information about the significant risks and benefits of the vaccine to
residents (or resident's legal representative) and employees; for example, risk factors that have been
identified for specific age groups or individuals with risk factors such as allergies or pregnancy. On
admission, each resident or the resident's representative will be provided with education regarding the
benefits and potential side effects of the immunization.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145981
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
FAQ · About this visit
Common questions about this visit
What happened during the March 14, 2025 survey of EVERCARE OF SWANSEA?
This was a inspection survey of EVERCARE OF SWANSEA on March 14, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EVERCARE OF SWANSEA on March 14, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.