Palm Garden of Mattoon: Abuse Protection Failure - IL
The resident, identified in inspection records as R7, was diagnosed with a fractured left tibia, gait abnormalities, muscle wasting, and a right above-the-knee amputation. A physician had ordered a left half side rail specifically to help her move in bed. On December 17, 2025, staff found her sitting on the floor beside her bed, the rail lying next to her. She had tried to use it to sit up, and it came off the frame.
The maintenance director told inspectors he believes nursing staff had removed and replaced the rail without securing it properly. The director of nurses confirmed that only maintenance staff are authorized to install bed rails, and confirmed the rail must not have been secured.
A second resident, R107, fell twice in eight days. Staff had known for several days before the first fall on January 1 that she was dizzy when standing. She fell anyway. She was sent to the emergency room with a headache and a large bruise on her sacral area. A family visitor told inspectors the fall could have been prevented with closer supervision.
On January 8, a therapy staff member walked R107 to the dining room and left without providing a wheelchair. The visitor told inspectors R107 was scared to walk alone, wanted the wheelchair, and would have used it. Without one, she fell again.
The facility's regional registered nurse told inspectors on January 29 that the facility had no documentation showing fall interventions were in place at the time of either fall. She said a bedside table was also missing from R107's room, describing it as standard equipment, and said she did not know why it wasn't there.
Palm Garden of Mattoon is disputing the citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Garden of Mattoon from 2026-01-29 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
PALM GARDEN OF MATTOON in MATTOON, IL was cited for abuse-related violations during a health inspection on January 29, 2026.
A physician had ordered a left half side rail specifically to help her move in bed.
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.