Palm Garden of Mattoon: Pressure Ulcer Care Failures - IL
The maintenance director at Palm Garden of Mattoon told inspectors on January 22 that nursing staff regularly remove and reinstall bed rails without securing them correctly to the frames. That, he said, is what he believes happened before the December 17 fall. The director of nurses confirmed it: the rail had not been secured, it came off when the resident tried to use it, and it posed a hazard.
The resident, identified in the inspection report 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, and lack of coordination. When she tried to sit up on the side of the bed and grabbed the rail, it fell to the floor. She went with it.
The second resident, R107, had been complaining of dizziness when standing for several days before she fell on January 1. A family member told inspectors R107 had a large bruise on her sacral area afterward and was sent to the emergency room with a headache. Eight days later, a therapy worker walked R107 to the dining room and left. No wheelchair. R107 was supposed to have one. The family member said R107 was scared to walk alone and would have used the wheelchair instead of trying to move on her own.
The facility's own regional registered nurse told inspectors on January 29 that the facility has no documentation showing fall interventions were in place at the time of either fall.
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 21, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on January 29, 2026.
That, he said, is what he believes happened before the December 17 fall.
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.