Palm Garden of Mattoon: Resident Lost Fingertip - IL
On the afternoon of September 29, 2025, the man was sitting on a folding chair in a coordinator's office at Palm Garden of Mattoon when he stood, lost his balance, and fell backward into the chair and down the wall. When he held up his left hand, his middle fingertip was barely attached. He had his finger in his mouth when he fell. The next day, an orthopedic surgeon amputated what remained.
Three nurses told inspectors the same thing: it was well known that this resident constantly put his fingers in his mouth, his nose, and inside his pants. It was common. It was long-standing. Nobody disputed it.
What they disputed, or simply couldn't answer, was what anyone had done about it. When inspectors asked each nurse what interventions were in place, the answers were nearly identical. "We just try to tell him to stop," said one. Another said staff would remind him and he'd comply, but couldn't say what changed after the fall. The nurse who completed the formal incident investigation told inspectors: "I don't know what we could have put in place to prevent him from injuring his finger like that or to prevent it from happening again."
The facility had no care plan addressing the behavior at all, before the injury or after. The MDS coordinator confirmed it should have been care planned and said she would update it. That conversation happened on October 14, 2025, two weeks after the amputation.
One nurse mentioned that fidget toys had been given to the resident to keep his hands occupied. She said that had started that same day, October 14, the day inspectors arrived.
Inspectors cited the facility for actual harm to the resident. The care plan still had no problem statement, no goals, and no interventions for the behavior that cost him his fingertip.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Garden of Mattoon from 2025-10-15 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 5, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on October 15, 2025.
When he held up his left hand, his middle fingertip was barely attached.
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.