La Bella of Freeburg

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent falls by failing to maintain working status of chair pad alarms for 1 (R2) of three residents reviewed for accidents.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all residents in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to send a resident (R3) to the emergency room for further evaluation and failed to follow hospice agreements that a resident (R2) is not to be transferred to the hospital for treatment without first notifying hospice for 2 of 4 residents (R2, R3) 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 and R3 not being sent out to the hospital as ordered. This failure also puts R2 at risk to incur unnecessary medical bills. This past non-compliance occurred 5/10/25 to 5/23/25.

Inspectors wroteBased on interview and record review the facility failed to notify 1 (R2) of 5 resident representatives of significant changes in status which were reviewed for change in status in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25.

Inspectors wroteBased interview and record review the facility failed to ensure that 1 of 3 (R2) residents or their representative reviewed for hospital transfer received sufficient preparation for transfer to the hospital in the sample of 8. This past non-compliance occurred 5/10/25 to 5/23/25.

Inspectors wroteBased on interview and record review the Facility failed to seek medical interventions in a timely manner for 1 of 5 residents (R48) reviewed for medical interventions in the sample of 49. This failure resulted in R48 sustaining a fracture and not being sent out to the hospital for two days and sustaining a fracture of her left ankle.

Inspectors wroteBased on interview and record review the Facility failed to ensure a resident was not injured while being pushed in their wheelchair during meal service for 1 of 4 residents (R48) reviewed for accidents in the sample of 41. This failure resulted in R48 sustaining a fracture to her left leg while being pushed by staff in her wheelchair.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 99 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure proper infection control guidelines were being followed for 6 of 22 residents (R20, R48, R28, R38, R42 and R60) reviewed for infection control in the sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for 1 of 2 residents (R23) reviewed for abuse in the sample of 41.

Inspectors wroteThe facility failed to ensure all bruises of unknown origin were thoroughly investigated for 1 of 3 residents (R48) reviewed for bruises of unknown origin in the sample of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent staff to resident abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 17. This failure resulted in V8, Certified Nurse's Assistant, CNA, being rough with R2 and verbally abusing R2. A reasonable person would not want to be treated roughly during care and verbally abused.

Inspectors wroteBased on interview and record review, the facility failed to implement a system in which staff immediately report allegations of abuse and injuries of unknown origin to the Administrator and State Agency. This has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to properly investigate allegations of verbal and physical abuse and injuries of unknown origins for 4 of 4 (R1, R2, R16, R17) residents reviewed for accidents and abuse in a sample of 17. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement progressive fall interventions, in 1 (R87) of 9 residents in the sample of 42. This failure resulted in R87 falling and sustaining a femur fracture and head laceration and being sent out to local hospital.

Inspectors wroteBased on observation, interview and record review, the Facility failed to store, prepare, and serve food in a manner which prevents potential contamination. This has the potential to affect all 96 residents living in the Facility.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the privacy and confidentiality of 4 of 6 residents (R5, R31, R70 and R82) in the sample of 42, by displaying identifying information that includes their names, date of birth s, room location, care needs and code status in plain view of the public hanging over the residents' beds.

Inspectors wroteBased on interview, record review, and observation the facility failed to provide appropriate catheter care for one of four residents (R150) reviewed for catheter care in the sample of 42. Findings Include: R150's Care Plan dated 9/15/23 documents, resident (R150) has a urinary catheter. Interventions catheter care and treatment per current MD, (Medical Doctor), Observe/record/report to MD for signs and symptoms of UTI, (Urinary Tract Infection), which are pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. R150's admission summary dated [DATE] documents, R150 was placed on contact isolation for MRSA, (Methicillin Resistant Staph Aureus), and penile drainage. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform a safe transfer for 1 of 5 residents (R3) reviewed for resident injury in the sample of 6. This failure resulted in R3 sustaining a left tibial and fibular fracture which required hospitalization for surgical intervention.