Evervella of Swansea

Inspectors wroteBased on interview and record review, the Facility failed to answer call lights timely for 2 of 6 residents (R1, R3) reviewed for resident rights in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights in a timely manner in 1 of 7 residents (R20) when reviewed for accommodation of needs in the sample of 16. Findings Include: On 2/17/26 at 1:54 PM, R20 was observed in her room in the wheelchair. R20 stated she filed a grievance because it takes too long to get her call light answered and needs met. R20 stated it also depends on who is working, the agency staff are the worst, and it is worse during the night and on the weekends. R20 stated she has had diarrhea and when she needs to go, she needs to go and worries that the staff will not get to her in time and she will have an accident in her pants. R20 stated since filing the grievance, things have not improved and are the same. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure working call lights for 2 of 2 residents (R1, R3) reviewed for call lights in the sample of 6.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a working call light system for one resident (R3) of 5 residents reviewed for call lights in the sample of 6.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to continue intravenous antibiotics to 1 resident (R1) of 1 resident reviewed for antibiotic use in the sample of 5. This failure resulted in R2 being re-diagnosed with osteomyelitis and having a peripherally inserted central catheter (PICC) reinserted. During the onsite survey, past noncompliance was cited after the facility implemented actions to correct the noncompliance which included in services and quality assurance checks. The deficient practice occurred on 10/10/2025 and was corrected on 11/11/2025 prior to the start of this survey and was therefore Past Noncompliance. The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform adequate incontinence care to 1(R1) of 4 residents reviewed for incontinence care in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was an adequate number of CNAs (Certified Nursing Assistants) working to provide care to the residents. This failure has the potential to affect all 85 residents residing in the facility. Findings Include:On 9/23/25 at 9:24 AM, R35 stated that the facility is short staffed. On 9/23/25 at 9:40 AM, R28 stated that the facility is short staffed for CNAs. She stated that sometimes R28 has to wait 2 hours for her call light to be answered. On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they have cut down on staff. R75 stated within the past 2 weeks, unsure of exact date, he had to wait 3 hours to get his call light answered because they don't have enough. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer snacks to the residents. This failure has the potential to affect all 85 residents residing in the facility. Findings Include:On 9/23/25 at 9:18 AM R68 stated since the new company took over the place isn't worth a s***, they used to give us soda, candy, cookies for snacks, now they don't even offer snacks. R68's MDS (Minimum Data Set), dated 8/19/25, documents he has moderate cognitive impairment. On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they cut out their soda, fruit drinks at breakfast and evening snacks. R75 stated they don't offer any snacks. R75 stated about the only thing he likes is the hot dogs and he is getting tired of hot dogs. R75's MDS, dated [DATE], documents R75 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident's dignity in 1 of 1 residents (R104) reviewed for resident rights in the sample of 34. Findings Include:On 9/24/25 at 7:52 AM and 8:02 AM, R104 was observed in bed, uncovered with the blankets at the bottom of the bed, incontinent brief on, shirt pulled up under her breasts, privacy curtain pulled, resident not visible from door but once in the room, able to see around the curtain from bed one. R104's Minimum Data Set, dated [DATE], documents R104 has severe cognitive impairment and requires assistance with activities of daily living. R104's Care Plan, dated 9/19/25, documents R104 requires assistance with activities of daily living. On 9/25/25 at 1:33 PM V1 (Administrator) stated she would expect residents to be treated with dignity. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure the POA (power of attorney) was notified for change of condition for 1 of 3 residents (R19) reviewed for notification in the sample of 34.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure abuse did not occur for 2 of 3 residents (R5 and R23) reviewed for abuse in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive care plan for an indwelling catheter for 1 of 3 (R7) residents investigated for a catheter in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean and maintain a C-Pap (Continuous Positive Airway Pressure) and change oxygen tubing/humidifier in 2 of 2 residents (R16, R35) reviewed for respiratory care in the sample of 34. Findings Include: 1.) On 9/23/25 at 9:40 AM, R16 was observed with oxygen on at 3.5 liters/minute/nasal cannula. The oxygen tubing/cannula was not dated when it had last been changed. R16's Face Sheet, undated, documents R16 has a diagnosis of COPD (Chronic Obstructive Pulmonary Disease). R16's Care Plan, dated 9/24/25, documents R16 has impaired gas exchange. There was no documentation in R16's record as to when the oxygen tubing/cannula had been changed last. On 9/25/25 at 11:05 AM V2 (Director of Nurses) stated they are to change the oxygen tubing and humidifiers weekly. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure insulin pens and stock medication have legible expiration dates for 2 (R35 and R32) residents in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to serve palatable, timely meals to 3 of 4 residents (R16, R68, R75) reviewed for nutritive value/appearance/palatable/preferred temperature in the sample of 34. Findings Include:On 9/23/25 at 9:40 AM, R16 stated the food tastes horrible, they took away our soda and snacks. R16 stated they don't offer any snacks throughout the day or in the evening time. R16 stated sometimes she gets so hungry, she has to eat the food even though it tastes bad. R16's MDS (Minimum Data Set), dated 9/10/25, documents R16 is cognitively intact. On 9/23/25 at 9:18 AM, R68 stated since the new company took over the place isn't worth a s***, they used to give us soda, candy, cookies for snacks, now they don't even offer snacks. the food is worse than it was before, you get smaller portions. [...]

Inspectors wroteBased on interview and record review the facility failed to develop, promote, and implement a facility-wide system to monitor the use of antibiotics for 3 out of 5 residents (R106, R55 and R34) sampled for antibiotic use.

Inspectors wroteBased on observation and interview the facility failed to promote resident's dignity by answering call lights and addressing resident's needs for 4 of 4 residents (R1, R2, R3, R6) reviewed for Resident Rights in the sample of 6.

Inspectors wroteBased on interview and record review the Facility failed to seek medical interventions in a timely manner for 1 of 5 residents (R39) reviewed for medical interventions in the sample of 37. This failure resulted in R39 having a fall and not being sent out to the hospital for 2 hours and 34 minutes and sustaining a fracture of her left ankle.

Inspectors wroteBased on interview and record review the Facility failed to ensure there was a RN (Registered Nurse) working in the facility for 8 consecutive hours a day, 7 days a week. This has the potential to affect all 82 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an air gap present for the ice machine in the kitchen. This has the potential to affect all 82 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff had passed their required licensure exam for Licensed Practical Nurse before allowing them to work in the facility in the capacity of a license-pending graduate practice nurse. This has the potential to affect all 82 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the Facility failed to follow CDC Infection Control Guidelines during an COVID outbreak and staff providing patient care were not wearing the proper PPE (Personal Protective Equipment). This has the potential to affect 82 residents living in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide appropriate care for an indwelling urinary catheter to prevent infection in 1 of 4 residents (R45), reviewed for catheters in the sample of 37.

Inspectors wroteBased on interview and record review the Facility failed to ensure Physician Orders were followed and the physician was notified if the orders could not be carried out for 1 of 4 residents (R65) reviewed for physician orders in the sample of 37.

Inspectors wroteBased on interview, record review, and observation the facility failed to monitor medications to ensure the resident is not receiving unnecessary medications for one of five residents (R67) reviewed for unnecessary medications in the sample of 37. Findings Include: R67's MDS (Minimum Data Set) dated [DATE] documents R67 has moderately impaired cognitive skills for decision making. R67's EHR (Electronic Health Record) dated [DATE] documents R67's Unspecified Dementia Unspecified severity without behavioral disturbance, mood, disturbance, and anxiety. Vascular Dementia Unspecified Severity with behavioral disturbance, Restlessness and Agitation, and Major Depressive Disorder Single Episode Unspecified. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly care for a hospice resident with Dementia residing at the facility for Respite Care, including Activities of Daily Living (ADLs) and Medication Administration for 1 of 1 resident (R2) reviewed for proper nursing care. This failure resulted in R2 having significant behaviors resulting in R2 obtaining a leg injury.

Inspectors wroteBased on interview and record review the facility failed to have a Registered Nurse (RN) in the facility for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 78 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide a Registered Nurse (RN) for eight consecutive hours in a day. This failure has the potential to affect all 66 residents in the facility. The facility Nursing Schedule dated, Monday June 12th through June 29th documents. The facility has three RNs (V4, V10, and V25.) The facility did not have a RN for eight consecutive hours in a day on June 16th, 24th, 25th. On 6/29/23 at 11:00 AM V3 Director of Nursing stated our night nurse just walked in and resigned. We just don't have the RN coverage. The facility policy entitled, Direct Care Staffing dated, 12/2012 documents, the facility will comply with staffing requirements set forth by the State and Federal requirements to meet the needs of its residents. The Residents Census and Conditions of Residents Form dated, 6/27/23 documents the facility has a census of 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a manner that prevents potential contamination. This has the potential to affect all 66 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to establish and implement an infection control program which analyzed trends of infection. This has the potential to affect all 66 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to utilize the services of an Infection Preventionist (IP), at a minimum part time basis, to track facility infections and resident vaccinations in order to prevent the spread of infectious disease. This has the potential to affect all 66 residents living in the Facility.

Inspectors wroteBased on interview, record review, and observation the facility failed to provide progressive fall interventions for 7 out of 13 residents reviewed (R2, R12, R40, R44, R54, R58, R59) for falls in the sample 52. Findings Include: 1. R12's Electronic Health Record (EHR) Fall Investigation dated 6/19/23 documents resident lowered to the floor. R12's Fall Intervention for the fall is therapy to evaluate slide board use. R12's Fall Investigation dated 6/18/23 documents R12 had a fall, and no intervention was provided. R12's Fall Investigation dated 4/5/23 documents R12 was lowered to floor, and this fall did not have a Fall Intervention. R12's EHR Fall Investigation dated 3/26/23 documents R12 had a fall on this date, and R12's intervention was to give R12 a grabber. Minimum Data Set (MDS) dated [DATE] documents R12 is a limited assistance of one staff member for transfers and bed mobility. [...]