Accolade Healthcare Danville: Fall Leaves Resident with 14 Staples - IL
The resident, identified in inspection records only as R1, had just fallen face-first off the side of her bed and struck the bedside table. She weighed 343 pounds, could not stand, and needed maximum assistance to roll from side to side. The therapist had left her sitting on the edge of the bed, walked to the other side to try to pull her toward the middle, and let go.
R1 needed 14 staples to close the wound on her head.
The incident happened on October 31, 2025, at Accolade Healthcare Danville. Federal inspectors arrived days later following a complaint and documented what they found as causing actual harm.
The physical therapist assistant, identified in the report as V6, told inspectors she had been working with R1 that evening and asked R1 to sit on the side of the bed with a walker positioned in front of her for stability. V6 acknowledged R1 is dependent with bed mobility and does not stand. She said she recognized R1 was sitting on the edge of the bed, not safely in the middle, and attempted to correct that by walking around to the other side. She let go of R1 to do it.
R1 fell forward. Face first.
Before starting the session, V6 said she looked outside the room to see if anyone was available to help. She didn't see anyone. She started the session anyway.
The licensed practical nurse who responded, V9, told inspectors the physical therapist assistant came and got her after the fall and told her there was blood all over the floor. V9 called 911 immediately. She was direct about what should have happened before any of it: given R1's weight and her need for maximum assistance, the PTA should not have started the therapy session until someone was available to help balance R1. V9 said the PTA never asked her for assistance.
R1's nurse practitioner, V10, had been following R1's condition closely. She told inspectors that R1 had declined since her most recent admission, that R1 is completely dependent on staff while rolling side to side, and that she requires maximum assistance with all activities of daily living. V10 was unambiguous about what the therapist's departure meant: R1 is alert and oriented, and the therapist walked away from her without holding on.
The facility's own Director of Nursing said V6 should have had two people in the room with R1 given that R1 is dependent and needs help with bed mobility, transfers, and dressing. The Director of Nursing told inspectors that the lack of safety concern, and the failure to have a second person present, resulted in the fall and R1's need for emergency medical treatment.
The facility had a written safety policy, revised in September 2023, that instructed staff to support the resident's body during all positioning, transferring, and ambulation, and to provide two or more persons to assist when necessary for resident and staff safety.
V6 knew R1's limitations before she walked into the room. She looked for help, found none visible, and proceeded alone with a patient who could not catch herself, could not stand, and was sitting — by the therapist's own account — on the edge of the bed.
R1 left that session with 14 staples in her head.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accolade Healthcare Danville from 2025-11-05 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 23, 2026 · Our methodology
ACCOLADE HEALTHCARE DANVILLE in DANVILLE, IL was cited for violations during a health inspection on November 5, 2025.
The resident, identified in inspection records only as R1, had just fallen face-first off the side of her bed and struck the bedside table.
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.