La Bella of Morrison: Medication Failures Harm Resident - IL
The nurse documented seeing no coughing during the two hours she had been near the resident, identified in inspection records only as R1. She told the wife that calling 911 was her choice if she wanted him evaluated. The wife called. His blood pressure was 90 over 60. His oxygen saturation on room air was 88 percent. By 1:00 in the morning, he was admitted to the local hospital with pneumonia.
That was October 26, 2025. Federal inspectors arrived at La Bella of Morrison on November 25 and cited the facility for medication errors that caused actual harm to R1, one of the most serious findings a nursing home can receive short of immediate jeopardy.
R1 had arrived at the facility struggling to communicate and trying to climb out of his chair and out of his bed. The administrator, identified in the report as V1, told inspectors she had placed him on one-on-one supervision from the day he arrived. "I started it for safety," she said. "I didn't want him to fall and get hurt."
What the inspection report documents is a gap between what R1's physicians ordered for him and what he actually received. The facility's own medication error policy, revised just weeks earlier on October 1, 2025, defines a significant medication error as one that "causes the resident discomfort or jeopardizes his/her health and safety." Inspectors determined that is exactly what happened here. The deficiency was cited at the level of actual harm.
The policy lists medication omission among the examples of errors, alongside medications given in a manner not consistent with a prescriber's order. The inspection record does not specify which medication or medications were involved, or how many doses R1 missed or received incorrectly. What it establishes is that the errors were significant enough to cause him harm.
His nursing progress note from the evening of October 26 reads as a portrait of a facility caught off guard by a family member who was paying closer attention than staff had been. The nurse noted R1 had been "napping off and on comfortably" near the nurses' station before his wife arrived. There were "no issues," the note said. Then the wife arrived, and within hours, an ambulance had been called.
The administrator's account of R1's condition on arrival makes the medication failures harder to explain away. She knew he had trouble communicating. She knew he was restless and at risk of falls. She put systems in place specifically because she recognized he was vulnerable. The one-on-one supervision she ordered was meant to protect him. The medication administration that followed did not.
La Bella of Morrison is a small facility in a rural stretch of northwestern Illinois. The inspection was triggered by a complaint, not a routine survey. Inspectors were there because someone had raised a concern, and what they found when they arrived was a resident who had already been hospitalized, a medication error policy that the facility had just updated, and documentation that showed the gap between the care R1's wife believed he was receiving and the care the records could support.
She had given him water because he was thirsty. She had called 911 because she knew he had pneumonia. She had done, in a single visit, what the facility had not done across the days he had been in its care.
R1 was admitted to the hospital that night. The inspection report does not say what happened to him after that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Bella of Morrison from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
La Bella of Morrison in MORRISON, IL was cited for violations during a health inspection on November 25, 2025.
The nurse documented seeing no coughing during the two hours she had been near the resident, identified in inspection records only as R1.
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.