La Bella of Freeburg

In the surveyor’s words

From the most serious findings on record at La Bella of Freeburg, in the surveyor’s own words.

• Actual harm, isolatedF690Aug 18, 2026

  Based on interview, observation, and record review, the facility failed to provide complete and timely incontinent care for 2 of 3 residents (R9 and R14); reviewed for Bowel/Bladder Incontinence in a sample of 16. This failure resulted in R14 expressing feelings of embarrassment and displaying dissatisfaction with care.Findings include:1.R14's Facesheet with a print date of 8/13/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, acute cystitis, chronic obstructive pulmonary disease, chronic kidney disease and difficulty walking.R14's Minimum Data Set (MDS) dated [DATE] documented she was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene and was dependent on staff for toileting transfers. […]

• Actual harm, isolatedF689Jun 16, 2026

  Based on interview and record review the facility failed to safely transfer a resident via mechanical lift for 1 of 3 residents (R1) reviewed for falls in a sample of 5. This failure resulted in R1 falling and sustaining a laceration to her head which required an emergency transfer and treatment at local hospital. This past noncompliance occurred from 4/28/26-4/29/26. Findings Include:R1's admission Record documents an admission date of 9/16/2019 with the following diagnoses in part; unspecified dementia, mild with psychotic disturbance, dementia in other diseases classified elsewhere, severe with agitation, Generalized anxiety disorder, postural kyphosis, cervicothoracic region, polyosteoarthritis, unspecified.R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for… […]

• Actual harm, isolatedF689Nov 26, 2025

  Based on interview and record review the Facility failed to provide proper supervision to prevent a fall for 1 of 15 (R1) residents reviewed for supervision of falls in the sample of 42.This failure resulted in R1 being sent to the hospital on [DATE] for a fall which resulted in a facial laceration on her scalp and required her to have her scalp glued back together. Findings include:R1's Physician Order Sheet (POS) for November 2025 documents a diagnosis of anxiety, restlessness, and agitation, unsteadiness on feet, a history of falling and weakness.R1's Facesheet documents she was admitted to the facility on [DATE] for therapy then transitioned to a long-term resident.R1's Minimum Data Set (MDS) dated [DATE] documents she is severely impaired. […]

• Actual harm, isolatedF600Oct 21, 2025

  Based on observation, interview, and record review the facility failed to prevent abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 6. This failure resulted in R2 being cut on his face by a butter knife, falling from his wheelchair, subsequently requiring transfer to the local hospital for evaluation and treatment.Findings include:R2's face sheet documents an admission date of 4/7/2022. Diagnosis include Sepsis due to Streptococcus Pneumoniae, Dementia, Contracture of Left and Right Knees, Acute Respiratory Failure, Cerebral Infarction, Chronic Pain Syndrome.R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2's care plan updated 9/14/2025 documents R2 has a behavior problem: Attempting to make others feel sorry for him. […]

• Actual harm, isolatedF552May 30, 2025

  Based on interview and record review, the facility failed to honor care directives for 1 of 5 (R2) residents reviewed for quality of care in the sample of 8. This failure resulted in R2 being sent out to the hospital and having unnecessary diagnostic testing initiated before discovering (R2) was not the intended resident. This failure also puts R2 at risk for incurring unnecessary medical bills. This past non-compliance occurred 5/10/25 to 5/23/25. Findings include: R2's undated Face Sheet documents an admitted [DATE] with pertinent diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of left Posterior Cerebral Artery and Facial Weakness. R2's Care Plan dated 12/31/24 documents a focus of Advanced Directives. […]