La Bella of Freeburg: Resident Assault in Dining Room - IL
The resident who had been hit, identified in inspection records as R2, was on the floor. His head had come to rest on the foot pedals of his own wheelchair. He had a laceration under his right eye, on his cheekbone, and a small amount of blood. When the Director of Nursing reached him and asked what happened, R2 told her: "That guy clocked me."
Federal inspectors cited La Bella of Freeburg for failing to protect residents from abuse following a complaint investigation completed October 21, 2025. The citation carries a finding of actual harm, meaning inspectors determined the violation caused real injury to a real person, not a theoretical risk.
The resident who threw the punch, identified as R3, had no history of acting that way, according to the nursing assistant who witnessed it. She had been sitting at a nearby table, helping another resident eat, when she heard R2 scream. By the time she reached him, R3 was already leaving the dining room.
R3 turned to the nursing assistant as he walked away and said, "Get out of my face," followed by an expletive.
What staff found when they caught up with R3 in the hallway was a man in acute distress. He was saying his wife was cheating on him and his son was stealing from him. The Director of Nursing described him as irate, talking "crazy." Staff kept him separated from other residents and stayed with him until emergency medical services arrived. He was transported to the hospital first. R2 was sent out after him.
The incident happened on October 13, 2025, during the lunch hour, according to one of the nurses who responded. The inspection itself took place eight days later, on October 21.
The nursing assistant's account, given to inspectors at 7:58 in the morning on the day of the inspection, placed her close enough to hear R2 cry out but not close enough to stop what happened. She had been at a table near R2's table. She did not describe seeing the moment of impact. What she saw was R3 walking away and R2 in distress.
The registered nurse who responded described hearing someone yell "Help me, help me" from the Director of Nursing's office, where she happened to be at the time. She came out and saw R3 already leaving the dining room. Staff were already moving toward R2. R2 was on the floor. The nurse said R2 "thought he had gotten hit," a phrasing that suggests some initial uncertainty, though the physical evidence and R2's own statement to the Director of Nursing left little ambiguity about what had occurred.
Vitals and neurological checks on R2 came back normal. The laceration was described as very small. The bleeding was minimal. By the clinical measures available in the moment, R2 was not gravely injured. The inspection still found actual harm. A resident was struck in the face. He fell. His head hit the foot pedals of his wheelchair. He was taken to the hospital.
The LPN who called in the orders to transport both residents gave her account at 10:40 that morning. She said she had been walking back into the dining room when she heard R2 yelling that he was hurt and that his eye hurt. The Director of Nursing was already with R2. Other staff were already with R3, keeping him away from the rest of the residents.
What the inspection record does not contain is any finding that staff failed to respond in the moment. Every account describes nursing home employees moving quickly, assessing R2, separating R3, calling for emergency transport, and staying with both men until EMS arrived. The Director of Nursing ran from her office. The registered nurse came out of the same office. The nursing assistant left the resident she was assisting and went to R2.
The violation is not about what happened after R2 hit the floor. It is about the fact that he hit the floor at all.
The facility's own abuse policy, updated in December 2023, states that the home affirms residents' right to be free from abuse and that the facility prohibits mistreatment of residents. It describes the purpose of the policy as assuring the facility does everything within its control to prevent occurrences of mistreatment. Inspectors cited the facility under the federal standard requiring nursing homes to protect residents from abuse by anyone, including other residents.
R3's behavior in the immediate aftermath, his agitation, his disconnected accusations about his wife and son, his irate state, points to a man experiencing some kind of acute episode. Whether staff had any prior indication that R3 posed a risk to other residents that morning, or whether the episode came without warning, the inspection record does not fully resolve. The nursing assistant said R3 had never acted that way before. That account addresses his history, not the specific circumstances of that morning.
The dining room is a place where residents with varying cognitive and behavioral conditions sit in close proximity to one another, often for extended periods. It is one of the higher-risk environments in a nursing home for exactly this kind of incident. The nursing assistant was close enough to hear R2 scream. She was not close enough to intervene before R3 walked away.
R2 was taken to the hospital with a laceration on his cheekbone and a story about a man who clocked him at breakfast. His vitals were fine. His neurological checks were normal. The inspection record ends there, with R2 on his way out the door and R3 already gone, and a dining room full of other residents who had just watched it happen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Bella of Freeburg from 2025-10-21 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
La Bella of Freeburg in FREEBURG, IL was cited for violations during a health inspection on October 21, 2025.
The resident who had been hit, identified in inspection records as R2, was on the floor.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.