La Bella of Danville: Fall Safety Failures Cited - IL
The resident, identified in inspection records only as R5, has confusion that the facility's own assistant director of nursing acknowledged waxes and wanes. He tries to get himself out of his wheelchair and bed without waiting for help. His care plan listed fall interventions: a floor mat beside his bed, frequent toileting, keeping him occupied with activities.
On the morning of October 5, 2025, an unidentified nursing assistant heard a noise and found R5 sitting on the floor mat next to his bed. He was confused and could not explain why he had been trying to get up. A licensed practical nurse told inspectors that staff had last seen R5 in his bed shortly before, though she could not say when he had last been toileted. About thirty minutes after he was found on the floor, staff noticed swelling in his arm. They called the physician then and sent R5 to the hospital for X-rays.
The swelling came thirty minutes after they found him on the floor. The physician call came then, too. Not before.
The registered nurse supervisor, identified as V32, told inspectors she had not considered the October incident a fall because R5 was found sitting on the mat rather than the bare floor. She confirmed that no staff member had witnessed how he got there. She confirmed no family notification was made. She confirmed no physician was called at the time of the incident itself.
Six weeks earlier, on September 5, 2025, the same thing had happened. R5 was found on the floor mat, knees up. He told staff he had been cleaning the baseboard. The facility's director of nursing, identified as V2, told inspectors that staff reviewed the nursing note from that date and concluded R5 had placed himself on the floor intentionally, so it was not treated as a fall. No investigation was opened. No new interventions were developed. The physician was not notified. The family was not notified.
V2 confirmed that R5 was not witnessed putting himself on the floor on September 5. V2 confirmed the incident was not investigated. The facility's own fall policy, dated March 2018, states that unless there is evidence otherwise, when a resident is found on the floor it should be considered a fall.
There was no such evidence. Nobody saw what happened either time.
The administrator, identified as V1, told inspectors it could not definitively be determined that R5 had not truly fallen, since neither incident was witnessed.
Inspectors also found R5's call light sitting on his dresser, out of reach from his bed. The registered nurse entered the room during the inspection visit and moved it to the bed rail. She said R5 had not gotten out of bed yet that day and the call light should have been clipped within reach. There were no signs posted in R5's room reminding him to use the call light before attempting to move, a detail both the nurse and a certified nursing assistant confirmed when they walked through the room with inspectors.
The nursing assistant told inspectors R5 tends to try to transfer himself out of his wheelchair more than his bed, and that he does use his call light. The registered nurse said the same. The call light was on the dresser.
V2 told inspectors that for unwitnessed falls, the standard practice is to interview staff about when the resident was last checked and last toileted before the incident. V2 confirmed that for the October 5 fall, that information was not documented. The licensed practical nurse who spoke with inspectors said she was unsure when R5 had last been toileted before he was found on the floor that morning.
R5 ended up in the hospital with a swollen arm. What the X-rays found, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Bella of Danville from 2025-11-20 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 DANVILLE in DANVILLE, IL was cited for violations during a health inspection on November 20, 2025.
The resident, identified in inspection records only as R5, has confusion that the facility's own assistant director of nursing acknowledged waxes and wanes.
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.