Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Bella Of Freeburg during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and documented fall risk had care plan interventions that included use of bed and chair pad alarms. Facility policy and staff statements indicated that these alarms were to be functioning and checked each shift. However, the resident was found ambulating unassisted to the bathroom with a pad alarm in place that was not sounding, became unsteady, struck the back of the head on a bathroom door, and slid to the floor, demonstrating the facility’s failure to ensure the alarm was in working order.
Failure to supervise a high-fall-risk resident during toileting. A resident with a history of falls, weakness, unsteadiness, and severe impairment was assisted by two CNAs to the toilet using a gait belt, then left in the doorway while she sat on the toilet. She leaned forward and fell off the toilet, causing a forehead/scalp laceration that required hospital treatment with glue; staff documented that she was not watched at full attention.
The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week. Review of the nurse schedule showed multiple days without a documented 8-hour RN shift, and HR could not find RN coverage for several of those dates. The facility assessment called for a DON, ADON, 2-3 RNs, and 8-10 LPNs daily, and CMS form 671 showed a census of 95 residents.
A resident with moderate cognitive impairment was injured when another resident, who had no documented cognitive deficits but required neurological monitoring, attacked with a butter knife in the dining room. The altercation lasted over half a minute before staff intervened, resulting in a facial laceration and a fall from a wheelchair that required hospital evaluation. The incident occurred despite facility policies prohibiting abuse and requiring a secure environment.
A resident with a comfort-focused POLST and advanced directives was mistakenly transferred to the hospital due to staff confusion, despite no documented symptoms or need for outside intervention. The error resulted in unnecessary diagnostic testing before the mistake was identified, and staff interviews confirmed the transfer was not warranted.
Two residents experienced lapses in care when one was mistakenly sent to the ER without physician order or hospice notification, and another was not transferred to the hospital as ordered by the medical director. Staff confusion and failure to follow established protocols led to these deficiencies, with family and hospice not properly notified prior to transfers.
The facility did not properly notify the designated representatives and physicians for two residents regarding significant changes in their status, including a mistaken hospital transfer and a planned transfer that did not occur. Documentation indicated notifications were made, but interviews revealed delays and failures in communication, contrary to facility policy.
A resident with severe cognitive impairment was transferred to the hospital without prior notification or consent from her healthcare power of attorney. Facility records did not document any preparation or notification for the transfer, contrary to facility policy requiring such communication and documentation.
A resident in a LTC facility sustained a fracture after her leg was accidentally bumped by another resident's wheelchair. Despite showing signs of pain and increased bruising, an x-ray was not ordered until two days later, revealing the fracture. The facility failed to adhere to its policy for immediate notification of acute symptoms, resulting in delayed treatment.
A resident with severe cognitive impairment and multiple diagnoses was injured during meal service when her leg was bumped by another resident's wheelchair, resulting in a fracture. The incident was not immediately documented, and the facility's investigation was criticized for poor documentation and lack of clarity on the injury's cause.
The facility failed to store and prepare food properly, risking contamination for all 99 residents. Surveyors found improperly thawed chicken, undated and uncovered food items, and greasy kitchen hoods. The Dietary Manager was absent, and staff were unsure about the spoilage and cleaning schedules, violating facility policies and FDA guidelines.
The facility failed to follow infection control guidelines for six residents. CNAs were observed feeding residents without proper hand hygiene, and an LPN provided wound care without wearing the required gown under Enhanced Barrier Precautions. These actions violated the facility's infection control policies.
A resident with cognitive impairments and on blood thinners was found with a large bruise on her arm after a transfer. The facility failed to report this injury of unknown origin to the appropriate authorities, as required by their policy. The DON and ADON concluded the bruise was due to the resident's combative behavior, but inconsistencies in staff accounts and lack of proper documentation led to a deficiency in reporting suspected abuse or neglect.
A resident with severe cognitive impairment and mobility limitations was found with a bruise of unknown origin, which was not thoroughly investigated by the LTC facility. The incident report lacked details, and the investigation was poorly documented, resulting in a delayed diagnosis of a leg fracture. The facility's failure to adhere to its abuse policy led to a deficiency in care.
Failure to Maintain Functioning Pad Alarm Resulting in Unassisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning chair/bed pad alarm for a resident identified as being at risk for falls. The resident was admitted with multiple significant diagnoses, including chronic kidney disease, shortness of breath, anxiety disorder, torsades de pointes, sepsis, atrial fibrillation, heart failure, acute respiratory failure with hypoxia, restlessness and agitation, muscle weakness, unsteadiness on feet, cerebral infarction, and osteoarthritis. The resident’s MDS documented a severely impaired BIMS score of 4, and the care plan identified the resident as at risk for falls due to a history of falls on admission and weakness, with interventions including a chair pad alarm and bed pad alarm. The facility’s fall prevention policy required confirmation that bed/chair alarms are functioning when ordered, and staff reported that bed and chair alarms are to be checked for working status every shift. Despite these identified risks and interventions, an incident note documented that the resident was found ambulating unassisted to the bathroom, with the bed pad alarm in place but not sounding. During this unassisted ambulation, the resident became unsteady, turned, and hit the back of the head on a closed bathroom door, then slid to the floor and landed on the back. An LPN immediately assessed the resident, noting range of motion within normal limits, usual confusion, and a raised area developing on the posterior head. The administrator later confirmed that when the resident fell, the pad alarm was not sounding and that it should have been, indicating that the alarm was not functioning as required at the time of the fall.
Failure to Supervise a High-Fall-Risk Resident During Toileting
Penalty
Summary
The facility failed to provide proper supervision to prevent a fall for one resident who had a documented history of falls, unsteadiness on feet, weakness, anxiety, restlessness, and agitation. The resident’s care plan identified fall risk interventions including chair and bed pad alarms, moving the resident closer to the nurse’s station, and later noted a bed against the wall with a floor mat and re-education of staff after a prior toilet fall. The resident’s MDS documented severe impairment and substantial assistance needs for toileting hygiene. On the day of the incident, two CNAs assisted the resident to the bathroom after she yelled that she needed to have a bowel movement and was described as weak and needing two-person assistance. The CNAs used a gait belt and transferred her to the toilet, then stood in the bathroom doorway while she sat on the toilet. The resident leaned forward and fell forward off the toilet, sustaining a one-inch laceration to the forehead/mid-left forehead and above the left eyelid. She was sent to the hospital, where the scalp/facial laceration was treated with glue and CT scans showed no brain bleed or skull fracture. The incident report and staff statements documented that the resident was not watched at full attention and that staff believed they should have been closer to her given her history and alarms.
RN Coverage Not Provided for Required 8 Consecutive Hours
Penalty
Summary
The facility failed to provide the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week. Review of the facility's nurse schedule from 8/22/25 through 11/27/25 showed that an RN did not work a consecutive 8-hour shift on 8/30/25, 9/10/25, 10/12/25, 11/5/25, and 11/22/25. The facility assessment dated [DATE] stated that the facility requires licensed nurses providing direct care for day shift, evening shift, and night shift, including 1 DON, 1 ADON, 2-3 RNs, and 8-10 LPNs daily. On 11/25/2025 at 12:34 PM, the HR representative stated they could not find any RN coverage for 8/30/25, 9/10/25, 11/15/25, and 11/22/25. CMS form 671 dated 9/30/25 documented a census of 95 residents.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent abuse for one of three residents reviewed for abuse, resulting in a resident being cut on the face with a butter knife and falling from a wheelchair, which required hospital evaluation and treatment. The incident occurred in the dining room, where two residents were seated at separate tables. One resident, who had diagnoses including anxiety disorder, dementia, and chronic atrial fibrillation, stood up, took a butter knife, and stabbed another resident in the cheek. The altercation lasted approximately 35 to 40 seconds, during which the injured resident slid from the wheelchair and landed on the floor. The resident who was attacked had a history of sepsis, dementia, contractures, and chronic pain syndrome, and was documented as moderately cognitively impaired. The care plan for this resident noted behavioral issues such as attention-seeking and fixation due to anxiety and depressive disorders. The attacking resident had no cognitive deficits documented but was noted to have an alteration in neurological status requiring cueing and reorientation. Staff in the vicinity responded after hearing the injured resident scream, and immediate assessment and first aid were provided. The incident was captured on video surveillance, confirming the sequence of events. Staff interviews indicated that the attacking resident had not previously exhibited such behavior and that staff were present in the dining room but did not prevent the incident. The facility's abuse policy affirms residents' rights to be free from abuse and outlines the facility's responsibility to prevent such occurrences. Despite these policies, the incident occurred, resulting in physical harm to a resident and the need for hospital transfer.
Failure to Honor Advanced Directives Leads to Unnecessary Hospital Transfer
Penalty
Summary
A resident with a diagnosis of cerebral infarction and facial weakness, who had a care plan and POLST indicating a preference for comfort-focused treatment and limited hospital transfers, was mistakenly sent to the hospital. The resident's care plan specifically directed that hospital transfer should only occur if comfort could not be achieved in the facility. On the date of the incident, there were no documented vital signs or medical symptoms for the resident, and no nurse's progress notes indicated any concerns. A late entry in the nurse's notes later clarified that the resident was sent to the emergency room due to low blood pressure and low oxygen saturation, but this was a case of mistaken identity; another resident was actually intended to be transferred. Interviews with facility staff confirmed that the resident did not require outside intervention and that the transfer was not medically necessary. The Director of Nursing was unable to explain how the resident was taken by emergency medical technicians without the duty nurses' knowledge. The resident underwent unnecessary diagnostic testing at the hospital before the error was discovered. Facility policy requires that services be provided to maintain residents' physical and mental health and satisfaction, but in this case, the resident's advanced directives and care preferences were not honored.
Failure to Follow Physician Orders and Hospice Agreements During Resident Transfers
Penalty
Summary
The facility failed to follow physician orders and hospice agreements for two residents, resulting in significant lapses in care. One resident, who had a diagnosis of cerebral infarction and was on hospice care with a DNR/DNI status, was mistakenly sent to the emergency room for evaluation and treatment of low blood pressure and low oxygen saturation. The hospital identified that the wrong patient had been sent, and the resident was returned to the facility without receiving treatment. The family was not notified prior to the transfer, and the hospice provider was only informed after the incident. The facility did not have a physician order to send this resident to the hospital, and the hospice agreement specifically required prior approval before any transfer, which was not obtained. Another resident, who had been admitted with diagnoses including Human Metapneumovirus and SIRS, experienced a temperature elevation, abnormal lung sounds, and a significant drop in blood pressure. The medical director ordered this resident to be transferred to the hospital for further evaluation. However, due to an error, the resident was not sent to the hospital as ordered. The oncoming nurse reassessed the resident and decided to manage the symptoms at the facility without consulting the medical director or following the original transfer order. The resident's family was notified after the decision not to transfer was made. Interviews with staff revealed confusion and lack of clarity regarding the transfer process, with agency CNAs unfamiliar with resident names and roles. The facility's own policies and the hospice agreement required notification and coordination with hospice and family prior to any transfer, which did not occur in these cases. Documentation confirmed that the wrong resident was sent to the hospital and that a resident who should have been transferred was not, both in direct violation of physician orders and established protocols.
Failure to Notify Representatives and Physicians of Resident Status Changes
Penalty
Summary
The facility failed to notify the designated representatives and physicians of two residents regarding significant changes in their status, specifically related to hospital transfers. One resident, who was severely cognitively impaired and had a diagnosis of cerebral infarction and facial weakness, was mistakenly sent to the emergency room due to low blood pressure and low oxygen saturation. Although documentation indicated that the resident's power of attorney and the medical director were notified, interviews revealed that the power of attorney was not informed until two days later by a hospice nurse, and the medical director was not notified at all. The hospice nurse also confirmed delayed notification. In a separate incident, another resident, who was cognitively intact and had diagnoses including Human Metapneumovirus and SIRS, was reportedly not transferred to the hospital as initially planned. The resident's daughter was not informed by the facility about the transfer status and only learned through a hospital inquiry that her mother was not at the hospital. The medical director was also not informed that the resident had not been sent out as ordered and only discovered this during a routine visit. Facility policies require timely notification of residents, families, and physicians regarding transfers, but these procedures were not followed in these cases.
Failure to Notify Resident Representative Prior to Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident or their representative received adequate preparation and notification prior to a hospital transfer. Specifically, a resident with a diagnosis of cerebral infarction and severe cognitive impairment was transferred to the hospital without the knowledge or consent of her designated healthcare power of attorney, her daughter. The daughter reported that she was not informed of the transfer, and the resident was unable to speak or make decisions for herself due to her condition. Review of the resident's records, including the face sheet, MDS, and nurse progress notes, revealed no documentation that either the resident or her representative was prepared for or notified about the hospital transfer. The facility's policy requires that all discharge decisions, including reasons for discharge and discussions with the resident and family, be documented, and that required notices and appeals information be provided. This policy was not followed in this instance, resulting in a lack of proper documentation and notification.
Delayed Medical Intervention for Resident's Fracture
Penalty
Summary
The facility failed to seek timely medical intervention for a resident who sustained a fracture. The incident began when a bruise was noted on the resident's left shin during routine care, and the nurse practitioner was notified. Despite the resident showing signs of pain and increased bruising the following day, an x-ray was not ordered until two days after the initial incident. The x-ray revealed a fracture, and the resident was then sent to the emergency room for evaluation and treatment. Interviews with staff revealed that the resident, who was unable to propel herself in a wheelchair, was likely injured when her leg was accidentally bumped by another resident's wheelchair. The documentation of the incident was poor, and there was a delay in recognizing the severity of the resident's condition. The facility's policy required immediate notification of the nurse practitioner for acute symptoms, but this was not adhered to, resulting in a delay in treatment.
Resident Injury Due to Inadequate Supervision During Meal Service
Penalty
Summary
The facility failed to ensure a resident was not injured while being pushed in their wheelchair during meal service, resulting in the resident sustaining a fracture to her left leg. The resident, who had a diagnosis of major depression disorder, severe with psychotic symptoms, Alzheimer's disease, and dementia, was severely impaired for cognition and dependent on staff for daily activities. She was in a manual wheelchair and unable to propel herself. During a meal service, the resident's leg was bumped by another resident's wheelchair, leading to a bruise that later developed into a fracture. The incident was initially noted when staff observed a bruise on the resident's leg during routine care. The bruise was reported to the nurse, who monitored it and later ordered an x-ray when the bruise worsened. The x-ray revealed a fracture, and the resident was sent to the emergency room for evaluation and treatment. Interviews with staff indicated that the resident was sliding down in her wheelchair and was repositioned by staff when her leg was accidentally bumped by another resident's wheelchair pedal. The facility's documentation and investigation into the incident were criticized for being poor and lacking immediate and thorough reporting. The nurse practitioner expressed concerns about the late entry in the documentation and the lack of clarity on how the injury occurred. The facility's policies on abuse and accident/incident reporting require timely and thorough investigations, but the documentation in this case was found lacking, contributing to the deficiency.
Improper Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents potential contamination, affecting all 99 residents. During a tour of the kitchen, surveyors observed five large industrial bags of frozen chicken in a sink, with only one bag under running water at 100 degrees Fahrenheit, contrary to the facility's policy and FDA guidelines which require water temperatures below 70 degrees Fahrenheit for thawing. Additionally, the chicken was not fully submerged, and the water was not agitating the bags as required. In the walk-in refrigerator, uncovered and undated orange substance cups were found, along with a leaking box of glazed chicken, and a container of pineapple past its use-by date. A large container of corn kernels was also found without a date or label. The facility's Dietary Manager was not present during the inspection, and staff were unsure about the spoilage of the chicken and the cleaning schedule for the kitchen hoods, which were observed to be greasy and in need of cleaning. The facility's policies on meat defrosting and food labeling were not adhered to, as evidenced by the improper thawing of chicken and the presence of undated and expired food items. The FDA code requires proper thawing methods and clean ventilation systems to prevent contamination, which were not followed in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control guidelines for six residents, as observed during a survey. A Certified Nursing Assistant (CNA) was seen feeding a resident without washing or disinfecting her hands after touching her face and the resident's bib. This CNA then proceeded to feed another resident without performing hand hygiene. Similarly, another CNA was observed feeding two residents alternately without using hand sanitizer between feedings, and no hand sanitizer was available nearby. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of handwashing to prevent infection spread. Additionally, a Licensed Practical Nurse (LPN) provided wound care to a resident under Enhanced Barrier Precautions (EBP) without wearing the required gown, despite a sign on the resident's door indicating the need for personal protective equipment (PPE) including masks, gloves, and gowns. The Director of Nursing confirmed that staff are expected to wear the appropriate PPE for residents on EBP. The facility's policies on infection control and EBP were not followed, leading to these deficiencies in infection prevention and control practices.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R23, who was reviewed for abuse. R23, who has diagnoses including generalized anxiety, major depressive disorder, dementia, unsteadiness on feet, and muscle weakness, was found to have a large bruise on her right upper arm. The bruise was discovered by CNAs during a transfer from a wheelchair to bed, and the resident complained of pain during the process. Despite the severity of the bruise and the resident's cognitive impairment, the facility did not report the injury as required. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the bruise and conducted an investigation. They concluded that the bruise was likely caused by the resident being combative during care, a behavior noted as common for R23. However, there was no documentation that the Administrator was notified, and the investigation report lacked details on the exact statements from the CNAs involved. The facility's policy requires immediate notification to the Illinois Department of Public Health (IDPH) for potential mistreatment, but this was not done. Interviews with staff revealed inconsistencies in the accounts of the incident. The CNAs involved in the transfer did not report any unusual behavior from R23 that day, and one CNA stated that R23 was not combative or resistive to care. Despite these discrepancies, the facility did not follow its policy to report the injury to the appropriate authorities, resulting in a deficiency in handling suspected abuse or neglect cases.
Incomplete Investigation of Resident's Bruise Leads to Deficiency
Penalty
Summary
The facility failed to thoroughly investigate a bruise of unknown origin for a resident with multiple medical conditions, including severe cognitive impairment and mobility limitations. The resident, who was dependent on staff for most activities of daily living and used a manual wheelchair, was found to have an 11 x 6 cm bruise on her left shin during routine care. The incident report noted that the bruise was allegedly caused by another resident's wheelchair, but it lacked critical details such as the identity of the staff member present during the incident and the other resident involved. The investigation into the bruise was incomplete and poorly documented. The Skin Injury Investigation Checklist did not include the resident's name, and there were no documented interviews or statements from staff members involved in the incident. The Director of Nursing, who was new to the position, admitted to not documenting interviews or obtaining statements, which contributed to the lack of clarity regarding the incident. The Licensed Practical Nurse who initially assessed the bruise did not know the identities of the staff or resident involved in the collision. The facility's failure to conduct a timely and thorough investigation resulted in a delayed diagnosis of a fracture in the resident's leg. The Nurse Practitioner expressed concerns about the poor documentation and the lack of immediate reporting, which hindered the ability to determine the cause of the fracture. The facility's abuse policy emphasizes the importance of timely and thorough investigations, but this was not adhered to in this case, leading to a deficiency in the standard of care provided to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 304 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Freeburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Bella Of Mascoutah | 7 mi | ★★★★★ | 15 | 0 |
| Nexus At Mascoutah | 7.5 mi | ★★★★★ | 3 | 0 |
| Helia Southbelt Healthcare | 8.3 mi | ★★★★★ | 18 | 0 |
| St Paul's Senior Community | 9.5 mi | ★★★★★ | 10 | 0 |
| Evercare Of Swansea | 9.7 mi | ★★★★★ | 8 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for La Bella Of Freeburg.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.