Palm Garden of Mattoon: Finger Amputation After Fall - IL
The next morning, an orthopedic surgeon amputated what remained.
The resident, identified in inspection records only as R1, had cognitive challenges and a documented history of putting his fingers in his mouth, his nose, and his pants. According to federal inspection records reviewed after a complaint inspection on October 15, 2025, multiple nurses confirmed this was not a new behavior. It was not an occasional one. It was constant, and everyone on staff knew it.
The intervention in place was verbal redirection. Staff would tell him to stop. Sometimes he did. That was the plan. There was no care plan entry addressing the behavior at all, no documented interventions, and no goals to prevent injury to his fingers.
The LPN who serves as MDS Coordinator, identified as V3, was in her office when the fall happened. She told inspectors R1 was sitting in a folding chair, stood up, lost his balance, and fell backward into the chair and down the wall before sliding to the floor. She said R1 held up his left hand afterward and his left middle fingertip was just hanging. She believed his unsteadiness caused the fall. She said R1 having his finger in his mouth made it a lot worse.
V3 confirmed to inspectors that afternoon that R1 has a long history of putting his fingers in his mouth. When asked what interventions addressed the behavior, she said staff just tell him to keep his fingers out of his mouth. She acknowledged this should have been care planned. She said she would update the care plan.
Another nurse, V4, told inspectors R1 always has his fingers in his mouth, nose, or pants. When asked what interventions were used, she said: "We just try to tell him to stop." She did not know what, if anything, had changed after the September 29 injury.
A third nurse, V6, had responded to V3's office after the fall. She described finding R1 on the floor with what she called a straight line cut across his finger and fingernail. She confirmed it is common for R1 to have his fingers in his mouth. She also did not know what new interventions had been put in place. She mentioned that V3 had provided some fidget toys to keep R1's hands occupied, but added that this had only been initiated that day, October 14, more than two weeks after the amputation.
The nurse who completed the formal investigation of the fall, V8, was direct with inspectors. She confirmed interventions were never developed or implemented to address R1's history of putting his hands in his mouth. Then she said: "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 inspection record is blunt about what was missing. The facility's investigative file for the September 29 fall contained no documentation that anyone developed interventions to address R1's behavior. His active care plan included the fall and the fingertip injury as events. It did not include a problem statement, goals, or interventions to address the behavior that contributed to the severity of that injury.
Federal inspectors cited the facility for causing actual harm to R1, one of the most serious designations available under the inspection framework.
R1's cognitive challenges and his documented history of removing dressings factored into the surgical decision. The orthopedic surgeon's notes, referenced in the inspection, described a severely comminuted and markedly displaced fracture of the left distal phalanx. The amputation was almost complete, with only a small bridge of tissue remaining that contained no vessel capable of supporting reconstruction. Attempting to insert pins for repair would have been detrimental to the function of his hand given his level of unawareness and his tendency to remove anything placed on his body. The surgeon amputated the finger at the distal interphalangeal joint.
V3 noted R1 had no prior history of finger injuries. He did, however, have a long history of the behavior that caused this one. For years, the answer was to say something to him. After he lost part of his finger, the answer remained the same, for sixteen days, until an inspector arrived and asked what had changed.
The fidget toys were new that morning.
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.
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 25, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on October 15, 2025.
The next morning, an orthopedic surgeon amputated what remained.
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.