Palm Garden of Mattoon: Accident Hazards Harm Residents - IL
The resident, identified in inspection records as R107, had been complaining of dizziness when standing for "a few days" before she fell on January 1, 2025. A visitor told inspectors R107 ended up with a large bruise on her sacral area and was sent to the emergency room complaining of a headache. Eight days later, after therapy had walked her to the dining room, R107 had no wheelchair available. The visitor said R107 was scared to walk alone and would have used a wheelchair if one had been there. She didn't have one.
The facility's own 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 said staff should have been supervising R107 given the known dizziness complaints, and that a wheelchair should have been left with her in the dining room.
A second resident, R7, had a different problem. R7 had a physician's order for a left half side rail to help with bed mobility. On December 17, 2025, staff heard her yelling from her room and found her sitting on the floor beside her bed with the side rail on the floor next to her. She had tried to use the rail to sit up, and it came off the bed frame, taking her down with it.
The maintenance director told inspectors he believed nursing staff had removed and replaced the rail without securing it properly to the frame, which he said happens regularly. The director of nurses confirmed that only maintenance staff are supposed to install bed rails, confirmed the rail had not been secured, and confirmed that its failure caused R7's fall.
The facility is disputing the citation. R107, who wanted a wheelchair and would have used one, did not have one available.
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 violations during a health inspection on January 29, 2026.
The resident, identified in inspection records as R107, had been complaining of dizziness when standing for "a few days" before she fell on January 1, 2025.
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.