Evervella of Swansea

In the surveyor’s words

From the most serious findings on record at Evervella of Swansea, in the surveyor’s own words.

• Actual harm, isolatedF760Nov 21, 2025

  Based 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. […]

• Actual harm, isolatedF684Jul 26, 2024

  Based 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. Findings include: R39's Physician Order Sheet (POS) July 2024, documents a diagnosis of Pneumonia, unspecified organism; Unspecified severe protein-calorie malnutrition; Hypertensive encephalopathy; Memory deficit following unspecified cerebrovascular disease; Unspecified osteoarthritis, unspecified site; Essential (primary) hypertension; Other specified nutritional anemias; dry eye syndrome of unspecified lacrimal gland; Polyarthritis, unspecified;… […]

• Actual harm, isolatedF684May 23, 2024

  Based 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. Findings include: R2's Face Sheet, undated, documents R2 was admitted to the facility on [DATE] for a 5-day Respite stay and was discharged on [DATE]. […]

• Actual harm, isolatedF600May 3, 2023

  Based on interview and record review, the facility failed to prevent abuse by a staff member for 1 of 3 (R5) residents reviewed for abuse. A reasonable person would feel angry, intimidated, and fearful of staff from being hit and cursed at by a staff member. The findings include: R5's Care Plan, dated 03/10/2023, documents Problem: Cognitive skills for daily decision making moderately impaired - decisions poor; cues/supervision required d/t (due to) Dementia. It continues Approach: Engage in activities that do not require frequent decisions; observe for signs of frustration. Provide assistance as needed. It also documents Problem: Short-Term memory impaired - unable to recall after 5 minutes d/t Dementia, New Environment. […]

• Actual harm, isolatedF689Jan 11, 2023

  Based on interview, record review, and observation the facility failed to provide safe transfers for 2 of 3 residents (R1, R2) reviewed for transfers in the sample of 3. This failure resulted in R1 and R2 receiving severe skin tears. Findings Include: 1. R2's MDS dated [DATE] documents R2 is an extensive assist of one person for bed mobility, and total dependence of two staff members for transfers. R2 is moderately cognitively impaired. R2's Skin Integrity Care Plan dated 1/10/23 documents use mechanical lift for all transfers, and a avoid shearing residents' skin during transfers, positioning and training. […]