La Bella of Morrison: Community Pass Safety Failure - IL
The resident, identified in inspection records only as R1, told a state inspector on May 27, 2026, that he had signed himself out of the facility on the evening of May 17. He said he asked to go out on pass, went to his girlfriend's house, and stayed the night when it got late. He came back in the morning.
The facility's own sign-out log confirmed it. R1 had signed out at 6:30 p.m. on May 17.
What the medical record did not contain was any physician order approving a therapeutic leave. The facility's therapeutic leave policy, dated May 2026, is direct on this point: before a resident leaves for a non-medical visit, a nurse must obtain an order from the practitioner specifying approval. The policy also requires documentation of any medications sent with the resident and any education given before the leave.
None of that had happened.
The licensed practical nurse who worked the day R1 left told the inspector she had asked the administrator whether R1 was allowed to go. The administrator, identified as V1, told her R1 had a high enough cognition score that he could go. The nurse said she understood that normally you are supposed to call the doctor and get an order, but she went ahead based on what the administrator told her.
A registered nurse interviewed the same morning was more blunt. "Oh yeah," she said, "you are supposed to call the doctor."
The administrator's account was notably uncertain. She told the inspector that for a community pass, a resident needs a high cognition score. When asked about the physician order requirement, she said she was not aware of needing one or not, that nursing would know that, and that she would need to look at their policy. The policy, it turned out, was dated the same month the incident occurred.
R1's social services assessment did document that he had been evaluated for independent outside pass privileges and cleared on several measures: sufficiently alert and oriented, able to navigate community streets safely, able to propel a wheelchair carefully around cars and onto sidewalks. His care plan confirmed he could transfer himself independently.
But that same care plan listed his diagnoses: chronic congestive heart failure, anemia, a cardiac pacemaker, acquired absence of both feet, acquired absence of his right leg below the knee. And the care plan said nothing at all about community pass privileges or what conditions would govern them.
Inspectors rated the violation at minimal harm or potential for actual harm, and only one of three residents reviewed for community pass safety had the problem documented. The complaint inspection covered a sample of four residents total.
What the record doesn't answer is what would have happened if something had gone wrong overnight. R1 has a pacemaker. He has no feet. He was at a private residence, not a medical facility, without any documented review by a physician of whether the leave was safe given his conditions. The nurse who let him go did so on the word of an administrator who, weeks later, couldn't say whether a doctor's order was even required.
The administrator said she would need to look at the policy.
The policy had been written that same month.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Bella of Morrison from 2026-05-27 including all violations, facility responses, and corrective action plans.
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: August 12, 2026 · Our methodology
La Bella of Morrison in MORRISON, IL was cited for violations during a health inspection on May 27, 2026.
He said he asked to go out on pass, went to his girlfriend's house, and stayed the night when it got late.
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.