Palm Garden of Mattoon: Abuse Reporting Failures - IL
The resident, identified in inspection records as R7, had a physician's order for a left half side rail to help her move in bed. She has a right above-the-knee amputation, a fractured left tibia, muscle wasting, lack of coordination, and gait abnormalities. On December 17, 2025, staff heard her yelling from her room and found her sitting on the floor, the rail lying beside her.
The maintenance director told inspectors that nursing staff routinely remove and reinstall bed rails without securing them properly to the frame. He said that is what he believes happened to R7's rail. The Director of Nurses confirmed that only maintenance staff are supposed to handle bed rail installation, confirmed the rail had not been secured, and confirmed the unsecured rail posed a hazard that caused R7's fall.
A second resident, R107, fell twice in eight days. Staff knew for several days before her first fall on January 1, 2025, that she was dizzy when standing. No fall interventions were documented. She fell, developed a large bruise on her sacral area, complained of a headache, and was sent to the emergency room.
She fell again on January 8. A therapy staff member had walked her to the dining room but left without providing a wheelchair. R107 was supposed to have one. A family member told inspectors R107 was scared to walk alone after the first fall and would have used the wheelchair instead of attempting to walk on her own.
The facility's regional registered nurse told inspectors on January 29 that the facility had no documentation showing any fall interventions were in place at the time of either fall. She also noted R107 had no bedside table in her room, calling it a standard piece of equipment and saying she did not know why it was missing.
Palm Garden of Mattoon is disputing the citation.
R107's family member put it plainly: she wanted the wheelchair and would have used it.
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: August 4, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for abuse-related violations during a health inspection on January 29, 2026.
The resident, identified in inspection records as R7, had a physician's order for a left half side rail 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.