La Bella of Cahokia: Broken Bed Fall Causes Bleeding - IL
The resident, identified in the report as R2, described the pain at an 11 on a scale of zero to ten.
The bed had a broken locking mechanism. It would not lock into position and continued to move. Nobody fixed it before R2 fell. When inspectors asked the administrator whether she had known about the broken bed before the fall, she said she could not remember.
The facility's own medical director did not hedge.
"I think the facility failed in preventing R2's fall," said V19, the Medical Director, when interviewed by inspectors on September 17, 2025. "No one was answering his call light, and his bed was broke — that's a lot." He said the incident had "the potential for the resident to experience harm or death." He called it unacceptable. He said he was sorry it happened.
R2 described what followed the fall in his own words to inspectors. Staff came and got him in his wheelchair and brought him to the nurse's station to be assessed. He said he was bleeding all over the place. The trail of blood ran from his bed out into the hallway. They had to use towels to stop it.
The Maintenance Director, identified as V14, was interviewed on September 17 at 3:07 in the afternoon. He said he believed he first learned about the broken bed from a work order, then changed his account and said he had made a note about the bed during a morning meeting with department directors. He said he would have to look for the notes because he was not sure what day the meeting had taken place. He confirmed that the bed was eventually replaced entirely because the locking mechanism did not work correctly and the bed remained able to move even when it was supposed to be locked.
The administrator, V1, was interviewed the following morning. She said she could not put a date on when she became aware that R2's bed was not working properly. She said it was sometime after R2 was admitted and before or after the fall, but she was unable to remember which. She said she would expect staff to fix problems themselves if they were able to, and if not, to submit a work order or report the issue to a nurse manager. She said maintenance and nursing together would get it fixed.
They had not gotten it fixed before R2 fell.
The Medical Director told inspectors he would classify R2 as a fall risk and said there should have been a fall plan of care in place for him. The facility's own fall prevention protocol, dated March 2025, required a comprehensive fall risk assessment for every resident within 48 to 72 hours of admission, and required that residents identified as fall risks have an interdisciplinary care plan directing interventions toward their specific risk factors. The protocol stated the facility was committed to maximizing every resident's well-being and creating an environment that was as safe as possible.
R2's bed was broken. His call light went unanswered. He fell, and he bled, and the pain was beyond the scale he was given to describe it.
The deficiency was cited at the "actual harm" level, meaning inspectors determined that real injury, not just the risk of injury, had occurred.
The Medical Director's words at the end of his interview were not complicated. He said: "It's unacceptable and I absolutely agree the facility failed."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Bella of Cahokia from 2025-09-22 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 27, 2026 · Our methodology
La Bella of Cahokia in CAHOKIA, IL was cited for violations during a health inspection on September 22, 2025.
The resident, identified in the report as R2, described the pain at an 11 on a scale of zero to ten.
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.