La Bella of Morrison

In the surveyor’s words

From the most serious findings on record at La Bella of Morrison, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 24, 2021

  Based on interview, and record review the facility failed to prevent non-consensual sexual contact between two residents. This failure resulted in R2 experiencing non-consensual contact by R1. This applies to two of two residents (R1 & R2) reviewed for sexual abuse in the sample of ten. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 10, 2021 when R1 went through a connecting bathroom and avoided using the hallway to get into R2's room. R1 went into R2's room and fondled R2's penis. The Immediate Jeopardy was identified on May 20, 2021. V1 Administrator was informed of the Immediate Jeopardy on May 21, 2021. […]

• Actual harm, isolatedF689Feb 24, 2026

  Based on interview and record review the facility failed to safely transfer residents and in a manner to prevent resident falls and injuries for 2 of 5 residents (R1, R3) reviewed for resident safety and supervision in the sample of 7. This failure resulted in R1 sustaining a large leg skin laceration, during a transfer, that required emergent transport to a local hospital for suture repair. The findings include:1.R1's progress notes and hospital records dated 1/23/26 showed R1 sustained a laceration to her left lower leg while being transferred into bed by facility staff. R1 was emergently transported via ambulance to a local hospital for an evaluation of her laceration. R1's leg laceration was repaired with nine (9) sutures. […]

• Actual harm, isolatedF760Nov 25, 2025

  Based on interview and record review the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R1) reviewed for medication administration in the sample of 7. This failure resulted in R1 requiring 1:1 supervision related to increased restlessness and agitation and resulted in R1 not receiving prescribed antibiotics and being readmitted to the hospital with pneumonia. The findings include: R1's face sheet showed he was admitted to the facility 10/16/25 with diagnoses to include pneumonia due to other gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of prostate, Alzheimer's Disease, and heart failure. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was dependent upon staff for all cares. […]

• Actual harm, isolatedF686Mar 5, 2025

  Based on observation, interview, and record review the facility failed to ensure interventions were placed when a pressure injury was identified and failed to ensure treatments and pressure reducing interventions were in place for 2 of 3 residents (R33, R21) reviewed for pressure in the sample of 12. This failure resulted in R33 sustaining a stage 3 pressure injury to her coccyx. The findings include: 1. On 3/3/25 at 10:15 AM, R33 was in bed sleeping. R33's air mattress was deflated, and R33 was laying on the bed frame. The air mattress controller said standby. Heel protection boots were observed in R33's wheelchair in the room. At 10:19 AM, V3 Certified Nursing Assistant came into the room and said the air mattress controller was not supposed to say standby. […]

• Actual harm, isolatedF689Jan 3, 2024

  Based on observation, interview, and record review the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a left leg laceration requiring 29 sutures. The findings include: The facility's Reported Incident Final dated 12/29/23 shows on 12/27/23, R1 sustained a skin tear to left lower extremity. Per staff interviews on file, it was noted resident was being assisted by 2 Certified Nursing Assistants (CNA) from wheelchair to bed using a mechanical lift. During the transfer resident was noted to bump leg on wheelchair. On 1/3/24 at 9:15 AM, R1 was sitting up in a reclining wheelchair in her room. R1 had padded protection sleeves on both arms and lower legs. […]